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• Kanawha

  KISRA Emergency Assistance Program 

 * NOTICE: KISRA is no longer accepting applications for this program. All funds have been used. * 

BACKGROUND INFORMATION

I,

hereby authorize Utility Company, Landlord, Medical

Provider, Other Corporate Representatives *

release/exchange information from my records both verbal and written to assist me in resolving an  emergency situation which is (choose from list below):

This information will be released to the Kanawha Institute for Social Research & Action, Inc., (KISRA) staff. 

You must complete all three pages and submit required documents before your application can be processed. 

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