• Application for Assistance

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

NOTICE: HC Jesus Cares does not give CASH. A copy of the bills for which you are seeking assistance must be attached to this form. If approved, assistance will be mailed directly to the appropriate agency.

We encourage you to attend a church of your choice. Your relationship with Jesus is the most important relationship you will ever have.

The information I have provided is true and correct to the best of my knowledge. I give permission for HC Jesus Cares to communicate with service providers and other resources in an effort to verify the information on this application and to provide advocacy and case management assistance using Charity Tracker networking. I understand that my consent automatically expires after one year or sooner at my written request. I agree not to hold HC Jesus Cares liable for any release of information during active status of this application or signed release. I understand that providing incorrect or incomplete information may result in being denied assistance.

HC Jesus Cares does not discriminate against any person because of race, color, religion, sex, age, handicap, or ethnicity.