Save First Financial Universal Application

General Application
Name

First NameLast Name
Email
Mobile Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you with Vancouver Clinic or Holy Rosary?
Emergency Assistance

Answering the emergency assistance questions helps us determine your eligibility and assist you in the best way possible.
Are you interested in Emergency Assistance?
Who Are You With?
Emergency Assistance Eligibility Notice

Only members of one of the predefined organizations above are eligible for emergency assistance.
Which Location Do You Work At?
Which Department Do You Work In?
Have you applied for assistance before?
Please Give a Brief Description of Your Current Situation
What Steps Have You Already Taken?
What Bill(s) Do You Need Assistance With?
State your entire household's income from the last 30 days (take home/net)
Please break down the amounts of your household's income from the last 30 days (take home/net) by source.

0/255
Does anyone in your household receive any of these non-cash benefits?
Demographics

Answering the demographic question helps us connect you with resources specific to yourneeds and identify programs or resources tailored to specific populations,allowing us to serve you to the best of our ability.
Household Type
Do you own or rent your housing?
Housing Details
How many people are in your household (including yourself)?
What primary language is spoken at home?
Other Language Name
Gender
Cultural Heritage
Cultural Heritage Details
Country of Origin (if other than US)
Are you a US Veteran?
Employment Status
Employment Status Details
Program Questions

At Save First Financial Wellness, we ask about income, expenses, and non-cash benefits (such as SNAP or TANF) to better understand your financial situation and provide support that fits your needs. This information helps us determine eligibility for scholarships and our sliding fee scale, which is available to individuals and families earning up to 250% of the Federal Poverty Guidelines. All information is kept confidential and used only to ensure fair, equitable access to our services. Our goal is to meet you where you are and make financial education and coaching accessible to everyone.
Are you interested in Financial Education?
Are you interested in Financial Coaching?
The following questions are to understand your financial situation and help you find the best coach for your current financial position and goals.
What goal(s) do you want to work on during coaching?

0/255
Do you have any preferences on the type of coach you are matched with that we can try to accommodate? (i.e. gender, age etc.)
Coach Preference Details
Do you have a partner or spouse that will participate in coaching with you? If so, please add their name here.
Please check all of the boxes for days that you are generally available to meet with a coach. (Please note that availability of staff coaches are limited to weekdays during working hours, volunteer coaches are subject to personal availability and may include weekends).
Please provide details about the times you are available on the days you selected.

0/255
Are you interested in receiving coaching remotely or in person?
Are there challenges making it hard to be financially stable?
Are you interested in applying for a Financial Coaching scholarship if you are deemed eligible?
Are you interested in Resource Navigation? (For Oregon & Washington only)
What resources are you interested in?
Are there any additional resources or services you would like assistance with?

0/255
Is there anything else you would like us to know?
How did you hear about us?
Corporate/Faith Partner Name
Community Partner Name
Please specify
You must choose a service to submit your form. Please scroll back and choose: Financial Education, Financial Coaching or Resource Navigation.
Consent for Services and Acknowledgment of Agreement. By selecting "Agree" below and choosing to participate in the Save First Program, I acknowledge that I am agreeing to engage in financial wellness services and will follow the outlined commitments, including attending scheduled meetings, actively participating in the service process, and communicating any necessary updates to my staff contact. I understand that, upon request, Save First Financial Wellness will provide me with a copy of the forms I have signed for my records. This acknowledgment is my formal acceptance of services, and I agree to the terms and conditions set forth by the Save First Program. If you are a Clark County resident and qualify forservices under the County-funded program (including meeting the 200% FederalPoverty Level eligibility requirement), required client information anddocumentation may be shared with Clark County funders in accordance withcontract requirements.
Please only click the Submit button below once, unless you are clicking it again after resolving a field error.
Should be Empty:

General Application

Emergency Assistance

Demographics

Program Questions