How Can We Help?

Please fill in the form below if The Village Hands can help you.

How Can We Help?

First Name

Last Name Please use your last initial if this is more comfortable

Date of Birth

Phone

Address

Address Line 2

City

Zip

Number of people in the household

Number of children in the household

Ages and gender of children

Why do you need assistance? Please tell us about your circumstances

What are your immediate needs?

If you were referred by someone, please leave their name:

How did you here about us
(Online or something else?)

Phone

RELEASE STATEMENT:

I hereby grant to The Village Hands (TVH) the permission the unrestricted right and permission
to copyright and use, re-use, publish, and republish pictures and/or likenesses of me and/or my
children, those in which I may be included in whole or in part in any and all media for lawful
purpose including the right to:

Record my participation and or appearance on video tape, audio tape, film, photograph or any
other medium.

Use my name, likeness, voice and biographical material in connection with these recordings.

Exhibit or distribute such recording in whole or in part without restrictions or limitation for any
educational or promotional purposes which TVH and those acting on behalf and authorized to
deem all appropriate.

I hereby agree that I am of full age and have the right to contract in my own name. I have read
the above authorization, release and agreement, and I am fully familiar with the contents
thereof. This release shall be binding upon me and my heirs, legal representatives.

I authorize The Village Hands to release my information to any and all referral agencies to include, but not limited to, child assistance services, hospitals, housing agencies, and any other facilities that may offer assistance with my needs.

By checking this box, I agree to the terms of the Release Statement from The Village Hands listed above.

Signature

Date

By clicking the above button, I consent to be contacted by The Village Hands and Webit, Inc. at any email address or telephone number I provide, including, without limitation, communications sent via text message to my cell phone or communications sent using an autodialer or prerecorded message. This acknowledgement constitutes my written consent to receive such communications. I agree and consent to any applicable Terms and Conditions of Use or Privacy Policy available on this website.

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