Tell us about your practical needs

Request help

Submitting this form expresses interest in a possible introduction. It does not guarantee acceptance, a response, a supporter, a purchase, delivery, or any particular outcome.

Assistance request form

Fields marked * are required.

First name *

Last name *

Email address *

City or community

Province or territory *

Amazon.ca wishlist link

You may leave this blank if your list is not ready. Do not paste a street address.

What kinds of practical items would help?

Briefly describe what would help *

Preferred way to hear from us

Mobile phone number (optional)

You may leave this blank. If no number is provided, we will use your email address.

I confirm that I am at least 18 years old and currently live in Canada. * I agree that the people operating Lifeline US may use the information in this form to contact me about this request and a possible introduction. *

By submitting, you acknowledge the Terms of Service. This form is processed by Formspree. Please do not include financial information, government identification, medical information, passwords, or other sensitive personal details.