Help Ministry
Non-Member Request Form This form is to be retained in the HELP Ministry office.
Assistance Needed?
*
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Sex
*
Male
Female
DOB
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Head of Household
Yes
No
Have you attended one of our StoneWater Church campuses?
*
Yes
No
Campus
*
Granbury
Glen Rose
Cleburne
Tolar
Godley
Snyder
I don't attend
Other
Do you attend another church?
*
Yes
No
Are you interested in hearing more about the Gospel?
Yes
No
Name of Church
Marital Status
*
Single
Engaged
Married
Separated
Divorced
Widowed
Living Together
Date of Marriage
-
Month
-
Day
Year
Date
Spouse's Name
First Name
Last Name
Spouse's Dob
-
Month
-
Day
Year
Date
Is spouse living in your household?
Yes
No
Have you previously requested assistance from StoneWater Church:
*
Yes
No
How did you hear about the StoneWater Church Help Ministry?
Shared Case Management Software - Charity Tracker StoneWater Church RELEASE OF INFORMATION (ROI)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
CharityTracker", is a shared, computerized record keeping system that captures information about people experiencing need for emergency services, including but not limited to assistance with utility bills, medications, rent/mortgage payments, etc. StoneWater Church (Participating Agency) utilizes CharityTracker to track and share assistance provided for those individuals, along with other participating agencies, primarily in Hood County but might occasionally include surrounding counties.I understand that all information gathered about me is personal and private and that I do not have to participate in CharityTracker. I have had an opportunity to ask questions about Charity Tracker and to review the basic identifying information, which is authorized by this release for the CharityTracker Assistance Network Participating Agencies to share. I also understand that information about non-confidential services provided to me by Charity Tracker participating agencies may be shared with other Charity Tracker Participating Agencies. This Release of Information will remain in effect for 3 years from the date noted under my signature at the bottom of this page unless I make a formal request to this Organization that I no longer wish to participate in CharityTracker.
Dependent's Information
Dependent's Information
Dependent's Information
Dependent's Information
Dependent's Information
Client and/or Parent-Legal Guardian’s Agency Representative SignatureAuthorizing Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: