Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email Address
What is the preferred way to contact you?
Marital Status
Married
Separated
Divorced
Single
Other
Spouses Name
Children (Names, ages, living situation)
Relationship to Redeemer
*
Member
Regular attender
Visitor
Attend another church
Other
Name of other church attended
What is the need that you're hoping Redeemer can help with?
*
Describe the circumstances that have created this need
*
What steps have you taken to remedy this situation?
*
Have you had problems with drugs or alcohol abuse? Describe your history.
*
What's your highest level of education
No degrees
GED
High School
Vocational degree
Associates
Bachelors
Masters
Other
Current Employment (How long at present job? How many hours a week?)
Brief Work History
Describe your current living situation (e.g., alone, with family, roommates)
Please indicate which of the follow you receive and how much $ for each: Child support, alimony, SSI/SSDI, public assistance, unemployment, $ from roommates, other income
*
Please describe your other loan debt if listed above
Savings
Please list any of the following and $ amounts in savings account, IRA, 401K, Pension plan, annuity, etc.
DO NOT ENTER ANY ACCOUNT NUMBERS HERE.
