Christian Charity Request Form

Date*
Date Format: MM slash DD slash YYYY
Phone*
Name*
First Last
Age
Address*
Street Address Address Line 2 City State ZIP Code
Marital Status
Spouse/Partner Name
First Last
Number of adults in household*
Number of children in home
Employed*
- Yes
- No
- Recently lost job due to COVID-19
If yes, name of Employer/Business and City
If you lost your job due to COVID-19; List business and city where you were employed
Date you lost your job
Date Format: MM slash DD slash YYYY
Have you applied for unemployment?
- Yes
- No
Does anyone in your household receive government assistance?
- Disability
- Social Security
- EITC
- Housing Assistance
- Medicaid
- SNAP
- SSI
- TANF
What do you need help with (rent, utilities, food and supplies, etc.) If you are requesting help with a bill please list the name of the company or landlord and total amount due for each bill.*
If you are requesting help with a bill, bring it with you & show it to us through the glass doors. If you need help with food, household cleaning products and personal hygiene items please fill out the below forms also. Our supplies are limited so you may not get all that you ask for.
If you are not requesting Food or Caring Cupboard supplies, please scroll to the bottom of the page to submit your request.
Food Supplies
Food & recipe in a bag (Limit 1 or 2 for large families)
- Tuna-noodle casserole
- Spaghetti & meat sauce
- Mac-n-cheese with hot dogs
- Hamburger casserole
- Chicken & noodles with Alfredo sauce
Canned items: (Limit 8)
- corn
- green beans
- pork & beans
- mixed veggies
- fruit cocktail
- applesauce
- canned tuna
- canned chicken
- tomato soup
- chicken noodle soup
- canned evaporated milk
Other: (Limit 12)
- Instant potatoes
- peanut butter
- jelly
- mac & cheese
- saltine crackers
- regular rice
- instant rice
- graham crackers
- elbow macaroni
- eggs
- cereal for adults
- cereal for children
- pancake mix
- pancake syrup
- instant oatmeal packets
- pop tarts
- pkg sliced cheese
- pudding cups
- ramen noodles - beef
- ramen noodles - chicken
- bread
- hot dog buns
- hamburger buns
- margarine
- mayo
Meat Items: (Limit 3)
- Hamburger
- Hot dogs
- Bologna
- Cotto salami
- Pork loin chops
- Chicken Patties
Caring Cupboard Items
Cleaning Products (Limit 8)
- Dish soap
- Toilet cleaner
- All purpose cleaner
- Comet or Ajax
- Trash bags
- Aluminum foil
- Laundry Detergent
- Liquid fabric softner
- Dryer sheets
- Clorox
- Spray & wash
- Dishwasher Soap
Paper products
- Toilet paper
- Kleenex
- Paper towels
Personal hygiene products (Limit 8)
- Shampoo
- Conditioner
- Deodorant for woman
- Deodorant for men
- disposable razors
- Shaving creme
- Bar of soap
- Liquid hand soap
- Hand/body lotion
- Body wash
- Band-aids
- Cotton swabs
- Toothbrush
- Toothpaste
- Feminine hygiene tampons
- Feminine hygiene pads
Diapers
- Size NB
- Size 1
- Size 2
- Size 3
- Size 4
- Size 5
- Size 6
- Pull-ups size 2T-3T
- Pull-ups size 4T
- Pull-ups size 5T
- Pull-ups size 6T

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