Point of Contact (full name):
Mailing address: City: State: Zip:
Phone no.# 2) Phone no.#
Email:
Preferred method of contact:
Driver’s license State and Number:
Religious Organization:
Point of Contact (full name):
Mailing address: City: State: Zip:
Phone no.# 2) Phone no.#
Email:
Preferred method of contact:
Driver’s license State and Number:
Religious Organization:
(Does not discriminate, nor make discissions on the basis of religion.)
- How did you hear about 360 Family Ministries? ________________________________________________________________________
- Do you have any experience or contact with 360 Family Ministries in the past?
- Type of assistant needed? Type N/A where it does not apply
- Foreign Mission Support _____________________________
- Family Disaster Assistant _____________________________
- Counseling or referrals _______________________________
- Financial support ___________________________________
- Clothing, foods, shelter, ______________________________
- Transportation _____________________________________
- Other: Please specify ________________________________
- Date you would like your requested support (will try to meet demand): ______________
- Specify in detail what you would like, to include the amount or quantity. ______________________________________________________________________________________________________________________________________________________________________________________________________________
- State the reason for your request.
______________________________________________________________________________________________________________________________________________________________________________________________________________________
- Do you care to share what lead to this problem? If so explain.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Have you taken any other steps to get resolve? ________________________________________________________________________
- Is there any other information you wish to communicate about your need? ________________________________________________________________________
- Would you like to share with 360 Family Ministries your religious faith if any? ________________________________________________________________________
- Do you have any church affiliation or involved in any prayer group? ________________________________________________________________________
I hereby affirms that I have represented and expressed my need as clearly and honestly as possible.
Signature of Recipient: _________________________________________Date: ____________
Please print your name clearly ___________________________________