CARE REQUEST

What is your first and last name? *

Your email. *

Your phone number. *

How long have you been attending Christ Covenant Church? *

Reason Requesting Care. *

Please select the type of celebration. *

Please select need below. *

Please provide: First & Last Name of Child, Date of Birth, Child's Gender at Birth *

Please provide: First & Last Name of Child, Date of Adoption/Foster, Child's Age, Child's Gender at Birth *

Which type of visitation would you like? *

Please share the reason for your hospital stay. *

Hospital Stay Length: *

Hospital Address & Room Number: *

Please list the best way to contact you to schedule visitation. *

Please share the reason you're requesting a home visit. *

Your home address: *

Please list the best way to contact you to schedule visitation. *

Please share what your family has gone through and your current needs. *

Financial Health: Are any of the following behaviors affecting you or any member of your family? (Select all that apply) *

List current monthly income: *

LIST CURRENT MONTHLY EXPENSES:

Rent/Mortgage: *

Utilities (water, electricity, etc.): *

Car payment: *

Phone/Internet: *

List financial amount requested and reason for use: *

List timeframe of need: *

Do you have relatives who are able to assist you financially or with food or housing? *

Yes

Do you have any ongoing medical or emotional conditions that you would like us to be aware of? *

Yes

Thank you for submitting your benevolence request. Please know we are praying for you and your need. Someone from our benevolence team will follow up with you in the near future.

In the meantime, we encourage you to look through our emergency assistance packet. This packet has the names and numbers of several non-profits that are equipped to help individuals in similar situations as yourself. Click Here to download the packet.

*Please be aware that while we strive to help as many people as possible, financial assistance is not guaranteed. All requests are reviewed based on available resources and individual circumstances.*

Please share what happened: *

Please list First & Last Name of the person lost: *

Please list relationship to person: *

Please list your mailing address: *