Gethsemane Baptist Church Assistance Request Form

Gethsemane Baptist Church Assistance Request Form
Be sure information provided is accurate AND copies/pictures of bill(s) are uploaded prior to clicking the submit button.

Please Note: Submission of this request is not a guarantee of assistance, and you are encouraged to continue pursuing all possible options.
Name of person submitting request*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Best Phone Number to contact you*
Phone Number Type*

HomeMobileWorkOther
Are you a member of Gethsemane Baptist Church ? check one*

Yes, I am an Active MemberNo, but I am a Regular AttenderNo, I am an Infrequent AttenderI am a NOT A MEMBER (I do not attend)
Date of Birth *
example: mm/dd/yyyy
Age Range*
Gender*
Choose From Dropdown
Marital Status*
Choose from Dropdown
Race*

African American/BlackCaucasian/WhiteOther
Ethnicity*

Hispanic/LatinoNon-Hispanic/Non-Latino
Number in Household*
Type of assistance*

FoodHousing: Rent/MortgageUtilitiesPrescription Medication
Amount of Assistance Requested*
Enter Dollar Amount (eg. $25.00)
Household Income*
Monthly
Employment Status? (Select all applicable)*

Yes (Full-Time)Yes (Part-Time)Yes (Self-Employed)If UNEMPLOYED, click this box only
Are you disabled?*

YesNo
Briefly explain the circumstances that lead to your need for assistance:
Provide Supporting Documentation (if available)
Signature Indicates that I authorize the verification of the information provided by a Gethsemane Baptist Church representative.*

Clear
Upload copies/pictures of each bill you're requesting assistance with

Browse Files
*NOTE: Once reviewed, additional information may be requested/required Cancelof
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