First Name

Last Name

Today's Date

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Do you want to get texts about closures, etc. at this number?

Yes

No

Email

Do we have your permission to send newsletters, etc.?

Yes

No

Birthdate

Marital Status

Social Security Number

Employer

Monthly Income

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Your School District

Children Living With You -- Name | Date of Birth | M/F

Others in Your Home -- Name | Relationship | M/F

Skills/Duties

Transportation

Own

Lease

No Vehicle

Medical Insurance

Medicare/Medicaid

Work Benefit

Purchase Myself

No Coverage

Mortgage or Rent per Month

Do you have a church home?

Yes

No

If yes, name of church you attend

Other Agencies/Organizations that have helped you in the past 12 months -- Name | $ Amount | Purpose

Our goal is to help you achieve financial stability and life transformation. In order to help you do that, we need to hear your story so we understand all the challenges in your life. Please answer the questions below as fully as possible.

Why are you requesting assistance from Morning Star Church Resource Center?

How long have you been struggling financially?

What do you need in order to achieve financial stability?

How did you hear about MSCRC?

Client Confidentiality
For the sole purpose of determining eligibility for financial assistance and other services, I authorize MSC Resource Center to collect and store personal information about me, my family and my fiancnial situation. I authorize MSC Resource Center to discuss information I have provided with any utility, bank, or other organization necessary for fulfillilng my request for assistance. I also authorize MSC Resource Center to share my personal information with other local social service and non-profit organizations, incuding local churches and social service ministries. I understand MSC Resource Center uses a third-party service, Administry.io, to track and share requests for financial assistance, and that staff and/or volunteers from any agency with whom MSC Resource Center chooses to share information may potentially have access to review my information. I understand that my information will never be sold, nor will it ever be used for any purpose other than fulfilling financial requests that I alone have initiated. I understand the requested or provided information is needed to determine eligibility for financial assistance and other social services. I understand that I can revoke this consent in writing at any time. Any information already released may be used as stated on the consent. This consent is valid for one year, beginning today. This consent is not automatically renewable. It expires automatically at the end of the period specified unless revoked in writing sooner. By my signature below, I affirm that I have read this release or it has been read to me, and I understand its content.

Signature

Date