Application for assistance

1
Please verify that you are human* This field is required.Just making sure the Robots haven't taken over.
2
would you like to donate to the cause?
YESNO
3
Do you only wish to donate
YESNO
4
Does the person needing assistance live in Warrick County or the Surrounding area?* This field is required.Assistance is only for local residence at this time.
YESNO
5
Donation typeSelect one
Gofund.me
Credit/Debit card*
Cash
6
Name of Person filling out the form* This field is required.
First Name
Last Name
7
Email
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code? or
Receiving the email may take a few minutes, thank you for your patience!
8
Phone Number* This field is required.contact number used if selected
Please enter a valid phone number.
9
Name of Person needing assistance* This field is required.
First Name
Last Name
10
Household Size* This field is required.
11
Children in Household* This field is required.
12
Adults in household* This field is required.
13
Phone Number of Person needing assistance* This field is required.
Please enter a valid phone number.
14
Address* This field is required.Of the person needing assistance
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Description of Why this Person or Family should receive assistance.* This field is required.short essay on character values, sacrifices made for community or other reasons why assistance is deserved .
Huge
Large
Normal
Small
Ok
Ok
16
Reason for Need* This field is required.description of hardship
Huge
Large
Normal
Small
Ok
Ok
17
General need* This field is required.
Kids
Bills
Food
Medication cost
Other Hardship
18
Specific need Bills, Food, Repairs, child care, Etc.
19
Image of person in need / Family in needUsed with permission from family, or Individual for social media promotion of the campaign only after assistance is provided
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Not Required but preferred images kept in assistance file
Cancelof
20
Signature* This field is required.
Clear
21
Like our page for updates
22
For even when we were with you, we would give you this command: If anyone is not willing to work, let him not eat. James 2:26 And I tell you, ask, and it will be given to you; seek, and you will find; knock, and it will be opened to you. Proverbs 28:26We try to help all, but we want the the help to go to a deserving family or individual.
23
Donation powered by: CB Crafts using Square**When donations are made using Square Online Checkout or eCommerce API the fee is 2.9% + 30 cents.(About $.033 per dollar) To help us avoid paying these fees please consider a donation to our gofund.me or contact us for cash donation options. this ensures all funds go to helping the selected families.
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Description
USD
+ OR enter a custom value
Payment Methods
Credit Card
First Name
Last Name
Cash App
After submitting the form, you will be redirected to the Cash App Pay to complete the payment process.
Google Pay
After submitting the form, you will be redirected to the Google Pay to complete the payment process.
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
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