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Application for Assistance

Please enter your full name:*
Please enter a phone number where we can reach you:*
Please enter your complete mailing address (no P.O. Boxes):*
Please choose the type of assistance you are requesting:*
 Child Care
 Counseling/Healing
 Groceries/Food
 Rent or mortgage
 Safety/Shelter
 Utilities
 Other
Check here if you regularly attend church or other religious services:
Are you enrolled in any government assistance programs?*
 Yes
 No
Check here if you have extended family who can help you:
Please enter your email address:*


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