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CAP of Pearland

Community Assistance Providers

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Request for Assistance

IMPORTANT: Only paid Members of CAP of Greater Pearland may submit assistance requests.

Request for Assistance

Are you member of CAP of Greater Pearland? *

Yes, I am a current member of CAP

No

All requests for assistance must come through a paid member of CAP. To have your request considered, please reach out to a member of CAP to sponsor your request.

Tell us about you

Requestor’s name *

Requester’s organization

Requestor phone *

Requestor email *

Tell us about the person who needs assistance

Recipient’s name *

Recipient phone *

Recipient address

Recipient address

Recipient address

Recipient address

Recipient address

Recipient address

Recipient address

Tell us about the need

Crisis *

What assistance is needed *

Payment of a bill (rent, car, medical, etc.)

Gift card (H-E-B, Walmart, etc.)

Durable medical equipment (DME such as a walker or wheelchair)

Purchase of a non-DME item

What is the bill for? *

Rent

Utilities

Auto

Medical

OtherOther

BIll amount *

Recipient’s account no. *

Name of account *

Vendor *

Contact person at vendor *

Vendor phone *

Gift card type *

H-E-B

Walmart

OtherOther

Gift card amount *

$

Type of DME needed *

Wheelchair

Rollator

Walker

Hospital bed

Other, describe in detail:Other, describe in detail:

CAP maintains a storage locker of donated DME. We will attempt to fulfill this request from storage first, but if we do not have the requested item, please tell us where to get it.

Item to be purchased *

Item cost* *

$

Supplier *

Supplier contact

Supplier phone no.

Delivery

Delivery options *

Deliver to recipient address above

Delivery to other address

Delivery address *

Delivery address

Delivery address

Delivery address

Delivery address

Delivery address

Delivery address

Delivery contact *

Delivery phone number *

Additional information

Date required

Comments

Consent *

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