CACM Crisis Assistance Form
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.
* Required
Name/Head of Household
*
Your answer
Social Security Number
Your answer
Phone Number
*
Your answer
Address
*
Your answer
Address 2
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Age
*
Your answer
Race
Choose
American Indian or Alaskan Native
Asian
Black or African American
Hispanic
Native Hawaiian or Other Pacific Islander
White
Two or more
Unknown
Other / Not Specified
Number of Adults in Household
*
18 and older
Your answer
Names of Other Adults in Household
Your answer
Number of Children in Household
*
Under 18
Your answer
Names of Children in Household
Your answer
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