CACM Crisis Assistance Form

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Connellsville Area Community Ministries provides various types of assistance to families who are in a time of crisis. The Ministry can provide various types of assistance to any family who is currently living in the Connellsville Area School District. Due to limited funding, we are only able to help each family once in a 12-month period. All clients must meet organizational and federal guidelines to qualify for crisis assistance.

Name/Head of Household *

Social Security Number

Phone Number *

Address *

Address 2

City *

State *

Zip Code *

Age *

Race

Number of Adults in Household *

18 and older

Names of Other Adults in Household

Number of Children in Household *

Under 18

Names of Children in Household

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