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White Hall United Methodist Church

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Application

* Indicates required field

Name *

First

Last

Full Legal Name

Address *

Line 1

Line 2

City

State

Zip Code

Country

How long have you lived at this address? *

Which applies to your living situation? *

Own Rent Staying with family Staying with a friend None

Phone Number *

Sex *

Male Female

Age *

Less than 13 13-18 19-25 26-35 36-50 Over 50

Are you currently employed? *

Yes No

How long has this been your employment status? *

Less than 1 month 1-6 months 1-3 years Over 3 years

Choose One *

Single Married Widow/er Domestic partnership Common law marriage Live-in boyfriend or girlfriend

How many dependents live with you? *

What's your average yearly household income? *

Less than $10,000 $10,001-$25,000 $25,001-$40,000 $70,001-$100,000 > $100,000

This includes all sources of income from everyone in the household who contributes to household expenses

Choose all that currently apply *

Medicaid/Medicare Recipient SNAP Recipient WIC Recipient TANF Recipient Worker's Comp. Recipient Social Security Recipient Social Security Disability Recipient Healthcare Privately Insured Healthcare through Marketplace (sometimes called Obamacare)

Who is your primary doctor? *

Have you seen them in the past year? *

Yes No

How did you hear about us? *

What are you needing assistance with? Include any known estimated costs. *

Submit a copy of your Driver's License as shown below.

Upload File of Driver's License *

Max file size: 20MB

The funds you are applying for are funds of the White Hall United Methodist Church given by generous donors throughout our community for the purpose of assisting those with paying for mental healthcare. The committee reviewing your request will prayerfully discern the information provided above. This process typically takes 7-14 days from the day you complete your application. You will be notified as soon as a decision has been made. By checking the box below you affirm that all the answers on this application are correct to the best of your ability, and that, if approved, you commit to spend these funds for the intended purpose you have requested them. Furthermore, by uploading a copy of your driver's license and checking to box below on this application you consent to a background check. *

Agreed

I agree to receiving marketing and promotional materials *

Submit

To complete application other ways:

Download the calebs_climb_application.pdf below. Fill it out completely.
Make a copy of your driver's license (front/back).
Mail or drop off to the White Hall United Methodist Church: 300 Church Driver White Hall, AR 71602

calebs_climb_application.pdf
File Size:	101 kb
File Type:	pdf

Download File

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(870) - 247 - 1481

301 CHURCH DRIVE WHITE HALL, AR 71602