AGAPE ASSISTANCE APPLICATION

AGAPE ASSISTANCE APPLICATION

Agape Ardmore Assistance Application

We deeply respect your story and are grateful for the courage it takes to share it.Please fill out the information below and include as much detail about your story and current needs as you feel comfortable. Your story may be shared anonymously to help us raise funds. Your name will never be shared publicly. Funding availability varies each month based on donations, grants, and sponsorships. These stories help our supporters understand real needs within our community and inspire them to give or sponsor assistance.Once you complete the form, a member of our team will contact you as funds or resources become available. We are currently operating on a waitlist while we work to raise more funds. As resources become available, we will contact applicants directly. Assistance is not guaranteed, but it is still important to complete this form—it helps us show our funders the true needs within our community and opens the door for future support. Mission of Agape ArdmoreAgape Ardmore exists to love Ardmore more — by fighting poverty, restoring hope, and helping people rebuild their lives through faith, housing, and opportunity.
I am currently homeless (sleeping outside, in a car, or in an unsafe place)I am staying in a hotel or motelI am temporarily staying with family or friendsI have a rental or home, but I am at risk of losing it soon
housing voucher that supplements what I can pay upto 50%transitional housingany help I can get
Story & Background
Brief summary of your current situation What events led to your current housing need? How long have you been in this situation? What steps have you already taken toward stable housing? What are your goals for the next 3–6 months?
Support & Assistance Needs
Type of assistance needed (rent, deposit, utilities, furniture, transportation, food etc.)Are you open to case management, budgeting, or job-readiness support? Do you have reliable transportation?Are you interested in our “Work to Live” Program
Do you have transportation? If so what kind.
Do you currently receive help from other agencies? (list)
We work with other agencies that provide housing vouchers like the Family shelter or Light house. We accept all vouchers.
Your STORY.
Our goal is to meet you where you are and give you a helping hopeful hand out of a hard situation. Tell us about yourself, your family, and the hardships you are facing.
List names & ages of everyone in the household.
Sooner Care or other InsuranceStruggle paying rent and all bills on current incomeStruggle to find or afford child careSubstance Abuse and or Addiction in the homeDomestic violenceVerbal abuseCurrently receiving DHS food stamps assistanceDHS chilcare assistanceFacing evictionsFacing foreclosureDivorceReceiving social securityRecieving disabiltyNative AmericanActive MilitaryVeteranSingle motherSingle fatherGrandparents raising grandchildrenMultifamily householdkids in dhs custody or family member custody
Do you have criminal charges or open cases? Are you paying fines or lawyer fees? If so please list.
this will not disqualify you from receiving help. At Agape Ardmore, we are here to meet people where they are, not to judge. Your honesty helps us understand how to best support you and connect you with the right resources.
Are you physically & mentally able to work? If so what is your desired job and pay?
Do you currently receive any form of government assistance or disability benefits?(Examples: SSI, SSDI, SNAP, TANF, Child Support, Unemployment, etc.)
YesNot right now
Total household income $ .
Monthly living expenses total $ .
Monthly Household income. List your employer/hours/income.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
I, First Name Last Name - SSN: - DOB: Date of Birth I hereby authorize Agape Ardmore Inc., a nonprofit organization, to receive and review my personal and financial information for the purpose of securing sponsorships, donations, or assistance on my behalf.
Permission to Share your story has the power to inspire generosity and help us raise funds for housing, employment, and community support programs.Do we have your permission to share parts of your story on our Agape Ardmore website and social media pages to help encourage sponsorships and donations?(Your name, address, and identifying details will never be shared — only your story and general needs.

YesNot right now.
This Consent Expires 2 years after this date:
Date:
Date
Signature*

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