Emergency Financial Assistance Application

Emergency Financial Assistance Application
Date

MonthDayYear
Date
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone #
Email
example@example.com
Zion Hope Membership: To be a member of Zion Hope, you would have, at some point, come to the front of the church during the invitational period after the sermon and indicated that you wanted to join Zion Hope either by accepting Jesus Christ as your saviour for the first time, or by Christian experience.

Based on the statement above, are you a member of Zion Hope Church?

If you are a member of Zion Hope, have you connected with your assigned Deacon (please mark yes or no)? Yes No
Yes, am a member, and have participated in the life of Zion Hope in the last 90 days, in the following ways (choose all that apply):

I frequently attend Sunday morning worship in person.I frequently attend Sunday morning worship online.I make regular financial contributions to the churchI attend Bible StudyI attend Sunday SchoolI am frequently involved with one or more other ministries (like Missionaries, ushers, Men or Women's fellowship, Youth Ministry, Food Pantry volunteer, etcOther
No, am not a member, but have participated in the life of Zion Hope in the last 90 days, in the following ways (choose all that apply):

I frequently attend Sunday morning worship in-personI frequently attend Sunday morning worship online.I make regular financial contributions to the churchI attend Bible StudyI attend Sunday SchoolI am frequently involved with one or more other ministries (like Missionaries, ushers, Men or Women's fellowship, Youth Ministry, Food Pantry volunteer, etcOther
If you are a member of Zion Hope, have you connected with your assigned Deacon (please mark yes or no)?

YesNo
Assigned Deacon's Name
Deacon's phone number
Please explain briefly below the circumstances that brought about your need for assistance.
Please mark Yes or No to indicate whether you have called 211 or accessed the linkwww.connect2help211.org to explore other resources that may be available to assist you.

YesNo
If "yes", did you receive financial assistance?

YesNo
If "yes", list the date?

MonthDayYear
Date
Amount Received
Have you requested or received assistance in your household from Zion Hope Church before?

YesNo
If "yes", list the date?

MonthDayYear
Date
Amount Received
Check the Type of Assistance Needed: (Note: If requesting utility help, must have a disconnect notice

RentMortgageElectricGasWaterFoodClothingOther
Amount Requesting
Date Needed

MonthDayYear
Date
Must provide documentation to show proof of assistance needed.*

Cancelof
Would you be willing to attend a Get Out of Debt workshop?

YesNo
Should be Empty: