Help/Care Request

We are grateful for the opportunity to walk alongside you. Our desire is to support individuals and families with compassion and care. Kindly complete the information below so we can better understand your circumstances.

Your name *

Last name

Email address *

Date

Phone number

Phone type

Address

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Preferred Method of Contact *

Phone

Text

Type of Assistance Requested *

Rent or Housing Support

Utility Support (Electric, Gas, Water)

Groceries/Food Assistance

Transportation Assistance (Bus Pass, Gas Card, etc.)

Emotional or Spiritual Support

Meeting with a Pastor or Benevolence Team Member

Other

Amount Requested *

Total Amount Due *

Due Date (if applicable):

Household and Employment

We ask a few questions about finances simply to understand your situation more clearly and determine how we can best support you. Please answer as you are able.

Household Members (Names and Ages): *

Employment / Income Source: *

Monthly Income: *

Monthly Expenses: *

Name and Address of Landlord or Mortgage Company: *

Brief Description of Situation *

Please share a little about what is happening and how we can help:

Spiritual / Personal Care

We care not only about practical needs but also your well-being.

Are you currently connected to a faith community? *

Yes

Would you like prayer or pastoral support? *

Yes

Supporting Documents

Please include copies of bills, statements, or other documentation as your situation necessitates.

Have you received care or support from ECC before? *

Yes

If yes, when and what type of support?

Thank You

Thank you for taking the time to complete this form. We appreciate you reaching out, and a member of our team will be in touch with you soon.

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Experience Christian Church
info@experiencecc.org
215-839-0303

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