United Way of Lake County: Survey

HSRG Request

If you are looking for a PDF version of the survey, go to www.uwlakeco.org/findhelp.

1.

Please complete the following:

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Name:

First Required	Last Required

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Email: Required

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Street 1: Required

Street 2:

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City/State/ZIP:

City Required	State Required	ZIP Required

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Phone Number: Required

Employer:

Yes, I would like to receive e-mail from United Way of Lake County

Remember me. What's this?

2.

Question - Not Required - Are you with an organization that would like to receive multiple copies? If so, please indicate your organization's name and address, as well as an appropriate contact and phone number.

3.

Question - Not Required - If your organization would like more than a single copy of the Human Services Resource Guide, please indicate the quantity you would like to receive.

4.

Question - Not Required - Within the last year, have you or someone you know needed help from the kinds of organizations listed in the Human Services Guide?

5.

Question - Not Required - For individuals requesting a single copy of the Human Services Resource Guide. If you would prefer your single copy be mailed to an address other than the one provided above, please provide us with the correct shipping address below.