211 Emergency/Domestic Abuse Request

Please complete the entire form- your request cannot be processed without all information! We will call you when your order is ready for pickup. As always, this program is confidential and private. If you are uncomfortable providing any identifying information on this form, you may contact the main office directly at 508-435-6511 or request@projectjustbecause.org

Shelter/Safe House

If you currently live in a shelter or safe house, please list the name and contact info for the shelter/safe house.

Additional Information

The 211 Emergency program provides necessities such as clothing, shoes, bedding and housewares to help people in crisis get back on their feet. If you are fleeing a domestic abuse situation, have been the victim of a natural disaster and house fire, are transitioning from homelessness or incarceration, or have recently immigrated to Massachusetts as a refugee, please list all items needed in the form  below.  We will do our utmost to meet as many of your requests as possible. If you do not meet any of the criteria above but are still in need of necessities, please utilize our other programs including the Free Clothing Store open every week and the General Requests program open the first week of each month.

Adult #1

Women: please use a number size when possible. For example: “women’s 10”
Men: please specify waist x length for pants. For example: “men’s pants 36×30”

Adult #2

Women: please use a number size when possible. For example: “women’s 10”
Men: please specify waist x length for pants. For example: “men’s pants 36×30”

Adult #3

Women: please use a number size when possible. For example: “women’s 10”
Men: please specify waist x length for pants. For example: “men’s pants 36×30”

Adult #4

Women: please use a number size when possible. For example: “women’s 10”
Men: please specify waist x length for pants. For example: “men’s pants 36×30”

Child #1

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Child #2

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Child #3

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Child #4

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Child #5

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Child #6

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Demographic Information (optional)

This information is used for funding purposes only! Your answers will not impact the fulling of your order in any way (even if you choose not to complete it). The information gathered may help Project Just Because to receive grants to further benefit those in need. Thank you!
(Please select all that apply)
If you selected "other", please describe how you identify your ethnicity.

Submit

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