Submit a Need | EZ Form

Submit a Need - EZ Form

Please enter the details of your need below. If you are not currently a certified referral partner with Lift Up Local, our team will be in touch to begin the certification process. Thank you!

About You

Your Name*

First Last

Organization Name*

Organization Address

How Can We Reach You?

We would love to chat with you. How can we get in touch?

Your Email Address*

Your Phone*

Describe the Need

Explain the Story of the Need*

Who is in need? Why do they need the items?

What Items are Needed*

Include sizes, quantities and amazon links if applicable.

Impact Category

Select the most applicable choice.

Number of People Impacted

This field is for validation purposes and should be left unchanged.