NWH Assistance Request

Personal Information

First Name*

Last Name*

Date of Birth*

If you are currently houseless or do not have a current home or mailing address, please list the city and county in the address field below.

Phone Number*

Email Address*

Address Type

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Address

Address Line 2

Site of Current Residence

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Length of Residence

Have you lived in Hood River, Sherman, Wasco County, Klickitat, or Skamania County for the past 12 months? *

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What services are you seeking?*

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Please describe your request for services

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