Register a Need

Person Needing Assistance

Name:

Street Address:

City:

State: Zip Code:

Phone: Please input your phone number.

Email A value is required.Exceeded maximum number of characters.

Mailing Address (if different):

Date of Need: (mm/dd/yy) A value is required.Invalid format.

Urgency of Need:

Immediately (1-2 days)
Fairly Soon (3-14 days)
Can Wait a Little (15-30 days)

Name of Referring Person

Self Friend or Family Member

Referrer's Name:

Phone:

Email:

Advocate/Provider

Agency's Name:

Advocate Name:

Job Title:

Street Address:

City:

Zip:

Email:

Please describe your need:
A value is required.

This has been a challenge for me / my family because:

Delivery Method (of item):

Thank you for participating in the Golden Rule projecct. Please let us know if the program is of help to you. Please read the Need User Agreement below and indicate that you understand.

   • I understand that my participating in the Golden Rule project is voluntary
   • I agree that the sponsors and registered members / helpers are not liable for damages that may occur
   • I understand that there is a chance that my need may not be met and that I will be informed of the status of
     my request
   • I must provide an e-mail and phone number for communication
   • I have read and agree to the Person In Need (Recipient) User Agreement and Disclaimer (above) and agree to the
     Golden Rule Terms and Conditions.

This is required in order to participate in The Golden Rule Project.

Please make a selection. I Agree to the Person in Need Agreement and Disclaimer

OR