Support Request Form

Name

First Name

Last Name

Phone

(###)

###

####

In what city and state are you located?

Services are currently only available in the U.S.

What is your current professional title or occupation?

What are you interested in?

Caregiver Support

Other Support (provide details below)

Tell us a little about yourself and how we may be able to assist you.

If requesting caregiver support, these questions will be helpful in getting you the best information: - How old is your loved one? - Does he/she currently live with you or elsewhere/on his/her own? - Does he/she receive SNAP/EBT/food stamp benefits? - Does he/she currently have Medicare, Medicaid, or both? - If your loved one has Medicaid, what program type does he/she have? (CCSP, Source, etc.) - Does he/she receive disability? - What is the nature of their illness/disability?

How did you hear about us?

Please tell us if you learned about us through social media, or were referred by a friend or business so we can say thank you!

Confirm you understand the statements below.

Please all boxes below before submitting your form.

You will receive your initial response from Project Pitch via email. Please check your spam folder occasionally. Submission does not guarantee receipt of services. We will be in touch with you to discuss your needs.

Please note attendance of any events, workshops, or receipt of our services does not guarantee you any specific employment results or outcomes, however, we will do our best to support you!

Project Pitch Inc. is proud to be an equal-opportunity service provider and complies with all federal regulations related to non-discrimination. We care about our people and celebrate our differences. We want to work with talented, collaborative, and innovative people. We do not discriminate or make any decision based on race, color, religion, national origin, age, sex (including pregnancy, childbirth, or related medical conditions), marital status, ancestry, physical or mental disability, genetic information, veteran status, gender identity or expression, sexual orientation, or other characteristics protected by law.