Financial Assistance Application Today's Date* Date Format: MM slash DD slash YYYY Date of last visit to Journey Christian Church* Date Format: MM slash DD slash YYYY Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email*Email is our primary means of communicating with you. If you do not have email, please provide a phone number where you can always be reached. Enter Email Confirm Email Phone*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemale Marital Status*MarriedSingleHave you ever received help from Journey?*YesNoWhen? And for what need?*Do you currently attend Journey regularly?*YesNoDo you currently serve on any of our strategic service teams?*YesNoAre you currently involved in a community group?*YesNoAre you currently employed?*YesNoWhat is your place of employment?*What is the reason behind your unemployment?*Is your spouse currently employed?*YesNoWhat is their place of employment?*What is the reason behind their unemployment?*What is the crisis or situation that has caused you to ask for assistance?*If assisted by Journey, how will you pay for next month's rent, utilities, etc?*What is your need today?Example: Electric Bill, RentWhat is the total bill amount?*NameThis field is for validation purposes and should be left unchanged.