Financial Assistance

1
Your Name* This field is required.
First Name
Last Name
2
Today's Date* This field is required.
Date
Year
Month
Day
3
Do you actively attend Great Lakes Church?* This field is required.
Yes
No
4
Please check all that apply* This field is required.
I actively attend Great Lakes Church
I have served on a volunteer team at GLC in the last year
I have attended a small group at GLC in the last year
I have lead a small group at GLC
I have financially contributed to the mission of GLC
I have been baptized at GLC
I have gone on a mission trip with GLC
I have invited a friend to join me at GLC
None of the above
5
Your Employer* This field is required.
6
Your Social Security Number* This field is required.This form is encrypted and this data will be kept confidential, shared only with Stewardship Team
7
Your Age* This field is required.
8
Are You Married?* This field is required.
Yes
No
9
Any Children? If so, list their names & ages here
Huge
Large
Normal
Small
Ok
Ok
10
Best Phone Number to Reach you* This field is required.We will contact you using this number for a short follow-up screening call.
11
Best Email Address* This field is required.This will be used to share next-steps from Great Lakes Church
12
Current Residence/Mailing Address* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
Do you...* This field is required.
Rent Your Home
Own Your Home
Other
14
Upload a Photo of Your Driver's License* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
15
What are your needs?* This field is required.Select all that apply
Food
Shelter
Rent/Mortgage
Utilities
Car Repair
Medical Emergency
Other
16
Date Needed By* This field is required.What is the urgency of your need?
Date
Year
Month
Day
17
Amount ($) Needed:* This field is required.
18
Have you been helped previously by Great Lakes Church?* This field is required.
YESNO
19
Please explain the circumstances surrounding your current need* This field is required.
Huge
Large
Normal
Small
Ok
Ok
20
Doctor's Name & Contact Info (if medical help is needed)
21
Landlord or mortgage company name & contact info (If rent is needed):
22
Mortgage/Rent* This field is required.
23
Car Payment* This field is required.
24
Electric/Gas Bill* This field is required.
25
Water Bill* This field is required.
26
Phone Bill* This field is required.
27
Monthly Medical Payments* This field is required.
28
Other (please explain, or if none write N/A)* This field is required.
29
Company Name (who is requiring payment)* This field is required.
30
Company Phone Number (who is requiring payment)* This field is required.
31
Company Contact Person (who is requiring payment)* This field is required.
32
Company Address (who is requiring payment)* This field is required.
33
Account Number (or Apartment Number if for Rent)* This field is required.
34
Total Amount Due* This field is required.
35
Amount Requested from Great Lakes Church* This field is required.
36
Please upload photo(s)/PDF of the bill you'd like assistance with (you may add up to 2: .jpg, .png, or .PDF)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
37
Family/Friend 1 Contact Name* This field is required.
38
Family/Friend 1 Phone Number* This field is required.
39
Family/Friend 1 Amount they can help with* This field is required.
40
Family/Friend 2 Contact Name* This field is required.
41
Family/Friend 2 Phone Number* This field is required.
42
Family/Friend 2 Amount they can help with* This field is required.
Should be Empty: