Cleveland Chesed Center Application Form
Thank you for reaching out the Cleveland Chesed Center. Please answer the following questions to help us determine your eligibility for services.
* Required
Today's date
MM
/
DD
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YYYY
Last Name
*
Your answer
First Name
*
Your answer
Street Address
*
Your answer
City
*
Your answer
Zip
*
Your answer
Phone number
*
Your answer
E-mail Address
*
Your answer
How did you hear about the Cleveland Chesed Center? (Please provide the name of the person or organization who referred you, if applicable)
*
Your answer
Number of family members living at home
*
Your answer
Are you currently employed? (check all that apply)
*
Yes
No
Under-employed
Looking for a job
Other:
Required
Is your spouse currently employed? (check all that apply)
*
Yes
No
Under-employed
Looking for a job
Not applicable
Other:
Required
What is your annual household income?
*
Your answer
Are you affiliated with a synagogue?
*
Yes
No
If yes, which one?
Your answer
Are you currently receiving any other assistance? (Check all that apply)
*
Medicaid for yourself and/or your spouse
Medicaid for your children
Medicare
Food Stamps
WIC
HUD
Unemployment
Other government assistance programs
Financial assistance from an organization
Financial assistance from family/friends
None of the above
Other:
Required
What services are you looking to receive from our agency or one of our partner agencies?
Food and Household necessities
Clothing
Assistance applying for government programs
Job placement
Job training/readiness
Mental Health
Case Management
Personal finance/household budgeting
Other:
Please describe in brief any particular circumstances that have led you to reach out for assistance. (i.e. outstanding school loans, high insurance premiums, recent loss of employment, etc.)
*
Your answer
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