Families & Children Assistance Application

Mountain Heart Ministries provides assistance to families with children who are facing financial hardship, unexpected emergencies, or difficulty meeting essential needs. Our goal is not only to help with an immediate need when possible, but also to understand the circumstances affecting the family and identify resources, employment, education, or other opportunities that may help create greater stability for the future.

First Name of Parent or Guardian *

Last Name of Parent or Guardian *

Email Address

Phone Number *

Home Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Who is completing this application? *I am the parent or legal guardianAnother family member is helpingA friend or neighbor is helpingA church or community organization is helpingA school representative is helpingOther

How many adults age 18 or older currently live in the household? *Include yourself and all other adults who regularly live in the home.

How many children under age 18 currently live in the household? *Include all children under age 18 who regularly live in the home.

Please briefly describe who lives in the household and whether the adults contribute to household expenses. *You do not need to provide detailed personal information. Please tell us generally who lives in the home and whether the adults contribute toward rent, utilities, food, or other household expenses.

What are the ages of the children under age 18 living in the household? *Please list ages only. Example: 4, 8, 12, 16.

Please tell us what assistance you currently receive and what it helps provide.For example: SNAP helps with groceries, a church helped with last month's electric bill, or the school provides clothing or school supplies. Please include the organization or program when known.

Please tell us specifically what assistance your family needs and what has happened that caused you to need help at this time. *Please include any details that will help us understand your family's current situation and most important needs.

What is the approximate total monthly income received by everyone in the household? *Include income received by all adults in the household, such as wages, Social Security, SSI/SSDI, child support, unemployment, pensions, veterans benefits, or other regular income. Enter numbers only — do not use a dollar sign or commas. Example: Enter 2500 instead of $2,500.

Please list each adult age 18 or older living in the household and describe their current employment or income situation. *For each adult, please give their first name or relationship to you and indicate whether they are employed full-time or part-time, self-employed, unemployed, looking for work, retired, a student, a full-time caregiver, or unable to work. If employed, please include their type of work. Example: Spouse — employed full-time, construction Adult son — part-time, grocery store Mother — retired, Social Security

Would any adult in the household be interested in assistance that could improve the family's long-term financial stability? *Employment or job-search assistanceTechnical or trade-school trainingCollege or other educationProfessional certification or licensingHelp returning to the workforceHelp starting or growing a small businessBudgeting or financial-management resourcesNot at this timeOther

If an adult in the household is interested in employment, education, or training assistance, please tell us who is interested and what they would like to pursue.It's okay if they are not sure of a specific program. Tell us about the type of work, career, trade, education, or training that interests them.

Is the family's current need primarily a one-time emergency or an ongoing need? *One-time emergencyOngoing needBoth

What will happen if your family does not receive this assistance? *Please briefly explain how this would affect the children or other members of your household.

Have you contacted any other organization, church, agency, school program, or assistance program for help with this particular need? *YesNo

If yes, please tell us who you contacted and what assistance you received or were offered.Include the name of the organization, church, agency, school program, or other resource and the outcome of your request.

If you selected any needs above, please briefly explain what the children need.You do not need to provide the children's names. Please tell us their ages and what is needed.

Is there anything else about your family's situation that you would like Mountain Heart Ministries to know?Please share any additional information that may help us better understand your family's circumstances or needs.

What is the best way for Mountain Heart Ministries to contact you about this application? *Phone callText messageEmail

Verification Authorization *I authorize Mountain Heart Ministries to verify the information provided in this application with appropriate individuals, employers, organizations, agencies, schools, service providers, or other sources when necessary to evaluate my request for assistance.

Applicant Certification *I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that providing false or misleading information may result in my request being denied.

Assistance Acknowledgment *I understand that submitting this application does not guarantee that Mountain Heart Ministries will provide assistance. Requests are reviewed based on individual circumstances, available resources, and the ministry’s ability to help.

Electronic Signature — Please type your full legal name *By typing my name below, I acknowledge that this serves as my electronic signature on this application.

Date *