Application for Assistance
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
We will need proof of Address. Are you able to provide this?
Yes
No
Sex
Male
Female
Other
Date of Birth
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Household Size
Back
Next
Please list ALL of the individuals that live in the household ( Include name, Age and DOB)
Estimated Annual Household Income
Are you a Student?
Yes
No
Do you receive any of the following social services? ( Select all that apply)
SNAP/ FOOD STAMPS
WIC
TANF ( Temporary Assistance for Needy Families)
Meals on Wheels
Section 8/ Rental Assistance
SSI/SSDI
Unemployment
Other
Which programs are you applying for? ( Select all that apply)
Food Pantry
Temporary Emergency Housing Assistance
Clothing Pantry
Resource Assistance
Transportation
I understand that Food and Non-Food products are provided on a
FIRST COME, FIRST SERVED
basis.
I agree not to sell the food or non-food products.
I hereby knowingly and voluntarily release, waive and identify Free Word Outreach Ministry and it's employees, volunteers as well as donors from any and all claims, actions, suits and liability of any nature whatsoever brought as a result of acceptance of food or non-food items from Free Word Outreach Ministry.
Housing services are based on availability and funding. This is not a guaranteed service.
The Free Word Outreach Ministry will not be held liable for the outcome of resource services provided.
Information on this form is confidential and for grant writing purposes only. Information will not be disclosed for any reason to any person or agency.
By signing below, I verify the information in this application to be correct and true.
Signature
Submit
Should be Empty: