Financial Assistance Application

Today's Date*
Date of last visit to Journey Christian Church*
Name*
First Last
Address*
Street Address Address Line 2 City 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*
Gender*
- Male
- Female

Marital Status*
- Married
- Single
Have you ever received help from Journey?*
- Yes
- No
When? And for what need?*
Do you currently attend Journey regularly?*
- Yes
- No
Do you currently serve on any of our strategic service teams?*
- Yes
- No
Are you currently involved in a community group?*
- Yes
- No
Are you currently employed?*
- Yes
- No
What is your place of employment?*
What is the reason behind your unemployment?*
Is your spouse currently employed?*
- Yes
- No
What 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, Rent
What is the total bill amount?*
Phone
This field is for validation purposes and should be left unchanged.

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