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2-1-1 Directory
Application for Assistance
Please note: Beginning 8/1/24 we no longer offer emergency mobile deliveries.
If you need help filling out this form, please call (951) 703-3716, and leave a message.
Please allow up to 48 hours for a response to your request.
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Indicates required field
Name
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First
Last
Street Address
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City
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Zip Code
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Phone Number
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Email
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Date of birth (MM/DD/YY)
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What, if any, type of aid are you requesting from Legacy Shelters or one of their partners? (Select all that apply.)
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Employment
Food pantry
Community closet (i.e., household items, clothing &/or other necessities)
Medical
Housing
Rental assistance
Other
For community closet/other, please specify
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Do you need help obtaining an I.D., Driver's License or Social Security Card?
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Yes
No
Unsure
Including yourself, how many people slept in the same place with you last night?
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How many children under 18 are there in your household who are sleeping in the same location?
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What is the current problem you are experiencing? (You may list more than one.)
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For reporting purposes only, please specify your race:
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Asian or Asian American
Black or African American
Hispanic/Latino
Native American
Pacific Islander
White
Other
Unknown/decline to specify
You may upload applicable documentation here:
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Max file size: 20MB
Please accept
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I certify that the following information is true and authorize Legacy Shelters to verify any details I have voluntarily provided.
Typed Signature Required:
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Submit
Who we are
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2-1-1 Directory