Application for Emergency Relief | Lifeline Darling Downs

By completing this form, I acknowledge and agree that:

I am requesting material assistance through provisions provided by Lifeline Darling Downs and South West Queensland Ltd.
I consent to my details being shared with authorised representatives from Lifeline Darling Downs and South West Queensland Ltd.
I understand that these representatives may contact me via phone, email, or other provided contact details for the purpose of coordinating this support.
I understand that my information will be used only for the purpose of arranging this assistance and reporting to funding bodies, and will be handled in accordance with confidentiality and privacy requirements.
All information is collected and securely held by our organisation. If you have any questions about this Privacy Statement, please contact the Privacy Officer.

Date *

First Name *

Last Name *

Contact Email

example@example.com

Contact Number *

Please enter a valid phone number.

Date of Birth *

Address *

Address 2 *

City/Town *

State/Province *

ZIP/Postal Code *

Gender *

Country of Birth *

Do you identify as Aboriginal or Torres Strait Islander? *

What do you need help with?* *

Food & Essential Living Items

Clothing

Household Goods

Furniture Assistance

Pharmacy Assistance

Other

Comments

What can we help you find?