Humanitarian Assistance Request

🌍 Preferred Language of Communication:

Arabic

English

French

Spanish

Other

Full Name: Date of Birth: Gender:

Male

Female

Other

Prefer not to say

Preferred Contact Method:

Phone

Email

Other

Phone Number: Current Location (Country / City / Address): Current Legal Status:

🆘 Type of Assistance Needed:

Food & Water

Medical Aid

Psychosocial Support

Emergency Financial Support

Educational Support

Shelter / Housing

Legal Assistance

Employment / Vocational Training

Resettlement / Safe Relocation

Other

📄 Case Description: 📎 Supporting Attachments (Optional):

ID or Legal Documents

Medical Reports

Photos

Educational Documents

Other

✅ Consent:

I declare all information is accurate.

I consent to use my data for assistance purposes only.

Humanitarian Assistance Request Form