Application for A Monkey Helper

Thank you for your interest in applying for a Helping Hands monkey-helper. Below is a short questionnaire that will help our placement staff determine your eligibility for our program services. After completion of this questionnaire, Helping Hands staff will contact you to discuss your qualifications and the next steps in the application process which includes a written application, references, and video of your home or site visit.

First Name *Minimum number of characters not met.Exceeded maximum number of characters.
Last Name

*Minimum number of characters not met.Exceeded maximum number of characters.
Email

*Invalid format.
Address Line 1

*Invalid format.
Address Line 2

City

*Invalid format.
State Please select an item.
Zip Code

*Invalid format.
Phone

*Invalid format.
Date of Birth

*Invalid format.
Type of injury/illness:

*Invalid format.
Date of Injury/Onset of Illness

*Invalid format.
How long have you been disabled? (Minimum 1 year post injury or diagnosis to apply)

*Invalid format.
How did you hear about us? Please select an item.
Other Specified:

Type of Home: Please select an item.
Other Specificed

Who lives in your home? A value is required.
Are there children under the age of 15 living in your house?

If yes, list age(s) of children.

Do you use a wheelchair for mobility?

In a typical week, how many hours do you spend outside of your home?

How many caregivers/PCA's help you in your home during a typical week?

What else would you like to know at this time?
Thank you for your interest in receiving a Helping Hands service monkey.