CARE Form
If you are in need of assistance, please fill out this form. Please give us at 24-48 hours to respond.
Name
*
First Name
Last Name
Age
*
Marital Status
*
Please Select
Single
Married
Separated
Divorced
Widowed
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
I am needing help with:
*
Please Select
Finances
Physical (examples: moving, mowing lawn, getting a ride, etc.)
Spiritual (examples: walking through a difficult season of grief, divorce, terminal illness, job loss, etc.)
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Next
How were you referred to us?
*
What is your need? (Please be specific with the amount and what it is for.)
*
Do you have relatives living in this area?
*
Yes
No
Do they know of your current need?
*
Yes
No
Are you receiving any aid (financial or otherwise from a government agency? (un-employment, social security, workers compensation, etc.)
*
Yes
No
If you answered yes, what kind of aid are you receiving?
Are you receiving food stamps?
*
Yes
No
If yes, how much are you receiving?
Have you been employed locally in the past 3 months?
*
Yes
No
If yes, where?
Are you currently employed?
*
Yes
No
If yes, where?
Full or Part Time?
Full
Part Time
Are you a member of Harvest Time Bible Church?
*
Yes
No
Do you attend Church?
*
Yes
No
If yes, where?
If we are able to help you, how many people are involved in your household?
*
Please list family members, etc.
We reserve the right to deny, for any reason contrary to our bi-laws and constitution, the above applicant from aid that the applicant has requested.
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Next
How were you referred to us?
*
What is your need? (Please be specific, especially if there are specific dates for something such a move date.)
*
Please explain why you are needing aid in this situation. (For example, is there a physical ailment which prevents you from completing it.)
*
Do you have relatives living in this area?
*
Yes
No
Do they know of your current need?
*
Yes
No
Are you a member of Harvest Time Bible Church?
*
Yes
No
Do you attend Church?
*
Yes
No
If yes, where?
We reserve the right to deny, for any reason contrary to our bi-laws and constitution, the above applicant from aid that the applicant has requested.
Please briefly describe your current situation in which you are needing help.
*
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Next
Thank you. One of the members of our team will be reaching out to you shortly. If you are requesting financial or physical aid, please allow up to ONE WEEK for a response.
Submit
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