Request Items

Home Starter Program: Request Items

The Home Starter Program is a ministry of the Congregational Church of Amherst, NH, UCC. Our mission is to collect household goods to assist those in need transitioning into independent living. All work is provided by church volunteers or interested community members. Please use this form to let us know of your household needs for a client or for yourself. Upon submission of this form, a committee member will contact you to work out details.

Referring Agency Name*
Please provide the name of the referring agency as we work with several groups:
Referring Agency Contact Person*
We frequently need to contact the person referring the client and need the name of the individual, as we sometimes have to go through voice directory prompt:
First Last
Referring Agency Contact Phone #*
Please provide the phone number of the agency contact so we can reach out to for communication if necessary.
Referring Agency Email*
Please provide the email address of the agency contact so we can reach out to for communication.
Client Name*
First Last
Client Phone #*
If the client does not have a phone number please provide the number of a friend or relative we can contact. Agencies are closed on weekends, when we do the majority of our deliveries, and we need a way to contact the recipient.
Client Email if available:
Family Information:
Please provide the total number of people in the family, and ages of any children.
Estimated Timeframe
Please tell us when you expect the customer to need the household items.
Home Description / Needs:
Please provide the total number of rooms in the home to be furnished, including how many bedrooms. Please list household items needed, including number and size of beds. PLEASE LET US KNOW RIGHT AWAY IF THESE NEEDS CHANGE.
Address of Home (if known):
Please let us know RIGHT AWAY if the address changes.

Street Address Apt or Unit City State ZIP Code
What floor is the home located on?*
Is there someone available to move the furniture, or help move?*
- Yes we can do the moving
- We have someone that might be able to help
- Don't know yet
- No we are not able to help
Is there an elevator in the building?
- Yes
- No
- Don't know
Additional Information:
Please provide any other information that would be helpful for us to know.
Comments
This field is for validation purposes and should be left unchanged.

Home Starter Program: Request Items

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