Join Hands Ministry Application for Assistance

Application for Assistance
Please fully fill out this application according to your need. If you are requesting financial assistance, you must complete the budget portion in full and to the best of your knowledge. After submitting the form, our team will review your application and contact you to set up a meeting. Please note this process can take up to 7 to 10 days.

All information shared on this form will remain confidential within Join Hands Ministry. If another organization may be able to better help you, we will not share your information without your permission.
NOTE:

Join Hands Ministry is only able to help individuals and families living in Perry County (Pennsylvania) one time per 365 days. We will require ID for proof of residency. If the address on the application doesn't match the address on your ID, you must upload a yellow card with your new address with the ID. For additional information regarding this application, please call the office at 717-582-7844 or email info@joinhandspa.com.

Are you a Perry County, Pennsylvania resident?*

YesNo
Unfortunately, per our bylaws, Join Hands Ministry can only provide services to Perry County, Pennslyvania residents.
Upload Current Pennsylvania Driver's License or Pennsylvania ID*

If the address on your current driver's license or Pennsylvania ID does not match the address on this application please include the yellow change of address card.
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Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (best number to reach you)*
Email*
example@example.com
Marital Status *
Are there additional members of your household?*

YesNo, I live alone

Household Member (other than applicant)*

First NameLast Name
Birthdate*

MonthDayYear
Date
Relationship to Applicant*
School (if member is a child)
Other information.
Check box if you need to add more household members

Add additional household member(s)

Household Member

First NameLast Name
Birthdate

MonthDayYear
Date
Relationship to Applicant
School (if member is a child)
Other Information
Check box if you need to add more household members

Add additional household member(s)

Household Member

First NameLast Name
Birthdate

MonthDayYear
Date
Relationship to Applicant
School (if member is child)
Other Information
Check box if you need to add more household members

Add additional household member(s)

Household Member

First NameLast Name
Birthdate

MonthDayYear
Date
Relationship to Applicant
School (if member is a child)
Other Information
Check box if you need to add more household members

Add additional household member(s)

Household Member

First NameLast Name
Birthdate

MonthDayYear
Date
Relationship to Applicant
School (if member is a child)
Other Information
Check box if you need to add more household members

Add additional household member(s)

Household Member

First NameLast Name
Birthdate

MonthDayYear
Date
Relationship to Applicant
School (if member is a child)
Other Information

Are you currently employed?*

YesNo
Where are you employed?*
How long have you been unemployment or unable to work?*
Upload a copy of your last two (2) pay stubs*

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What type of financial assistance are you requesting*

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Do you currently own or rent your home?*

OwnRentOwn Home with Lot RentRent to Own
Landlord Name & Phone Number*
Note: Join Hands Ministry will contact your landlord to confirm amount owed.
What amount can you contribute towards this bill?*

What type of family assistance is needed?*

ChildcareOther
Upload invoice/bill from childcare provider*

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Please explain your need*
Upload invoice, bill, or estimate for the requested need*

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Check box if you have additional requests

Add additional request
What type of financial assistance are you requesting*

AutoFamilyHomeMedicalUtilities

Please explain your medical need.*
Medical Provider/Contact *
Medical Provider/Contact Phone Number*
Please enter a valid phone number.
Upload invoice and/or cost estimate*

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Check box if you have additional requests

Add additional request
What type of financial assistance are you requesting*

AutoFamilyHomeMedicalUtilities

What is the situation that has caused you to ask for assistance? *
If assisted by Join Hands Ministry, how will you handle this expense in the future? *

Code of Conduct

For the health, safety, and comfort of all clients, visitors, staff and volunteers, we ask that clients and visitors follow the guidelines/expectations in our Code of Conduct.

By clicking the submit button, I, the client is agreeing to the following terms:

- Be polite to all persons including Join Hands Staff and volunteers
- Respect all people, their property and Join Hands Ministry property
- Supervise children always
- Keep quiet on cell phones and electronic devices so that other clients, visitors, Join Hands Staff and volunteers can attend and focus on their work.
- Respect client privacy, when another client is with Join Hands Ministry staff or volunteer

The following are prohibited:

- Possession or use of any weapon
- Possession or use of street drugs or alcoholic beverages.
- Swearing, violence, or other disruption.
- Wearing clothing that has offensive words or pictures.
- Interfering with the care of a client.
- Using any form of tobacco inside and outside of all Join Hands Ministry properties. This includes e-cigarettes or vaping.

Clients and visitors who do not follow this Code of Conduct will be asked to leave Join Hands Ministry property. If serious circumstance, the police may be called. You may also be barred from Join Hands Ministry property indefinitely.
By typing your full name in the box below, you are providing your signature and acknowledging that you have read and understand the above statement. *
Type full name here.

Monthly Budget Form

Please complete the following budget assessment to the best of your abilities. Include income and expenses for all members of your household. By providing this information, it gives us more information on the best course of assistance to help meet your need.

Monthly Income (include income from all contributing household members)*

	Monthly Amount
Salary/Wages (net)
Cash Assistance
Child Support/Alimony (received)
Family Assistance
Pension
Social Security/SSI/SSD
Unemployment Compensation

Other Sources of Funding*

	Amount
Savings
Retirement
Emergency Fund
Other

Total Monthly Income

Monthly Expenses (Housing)*

	Monthly Amount	Past Due/Total Due	Other Info.
Rent/Mortgage
Home Repairs
Homeowners/Rental Insurance
Property Taxes
Furniture/Appliance Rental
Home Equity Loan

Monthly Expenses (Utilities)*

	Monthly Amount	Past Due/Total Due	Other Info.
Cable or Satellite
Cellular Telephone
Electric
Internet
Landline Telephone
PO Box Fee
Personal/School Loan(s)
Propane or Oil
Trash: pay bags or dumpster
Water and/or Sewer

Monthly Expenses (Groceries)*

	Monthly Amount	Past Due/Total Due	Other Info.
Food
School Lunches
Paper/Cleaning/Toiletry Supplies
Pet Supplies
Other

Do you receive SNAP benefits? If yes, how much? If no, type 0.*

Monthly Expenses (clothing)*

	Monthly Amount	Past Due/Total Due	Other Info.
Clothing/Uniforms
Dry Cleaning
Laundromat

Monthly Expenses (Transportation)*

	Monthly Amount	Past Due/Total Due	Other Info.
Vehicle Payment
Vehicle Insurance
Service or Repairs
Gas

Monthly Expenses (Health)*

	Monthly Amount	Past Due/Total Due	Other Info.
Diagnostic Testing/Med Supplies
Incontenence/Feminine Supplies
Doctor Visits
Life Insurance
Medical Insurance
Other Medicines (aspirins, etc.)
Prescriptions
Subscriptions/Membership Fees

Does your medical insurance get paid out of your paycheck?*

Monthly Expenses (Child Expenses)*

	Monthly Amount	Past Due/Total Due	Other Info.
Childcare
Children's Recreation
Diapers/Wipe
Formula
Other

Other Monthly Expenses*

	Monthly Amount	Past Due/Total Due	Other Info.
Court Costs/Fines/Legal Fees
Professional Fees
Credit Cards
Dining Out
Donations/Tithes
Entertainment/Streaming Services (Netflix, Disney+, etc)
Haircuts
Storage Unit
Tobacco/Alcohol/Vape

Total Monthly Expenses
Monthly Balance (this could be a surplus (+) or a deficit (-))
Bank Statements. Provide two (2) full months of bank statements for ALL bank accounts. Screenshots will not be accepted. Contact your bank or other money institution to tell you how to obtain your bank statements.*

Provide two (2) full months of bank statements for ALL bank accounts. Screenshots will not be accepted. Contact your bank or other money institution to tell you how to obtain your full bank statements.
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Should be Empty:

Application for Assistance

NOTE:

Monthly Budget Form