Emergency Relief Application
Email *
First Name *
Last Name *
Email *
Phone number *
Who are you seeking assistance for? *
Required
What form of assistance are you applying for? *
Required
Please provide the total amount of financial assistance you are seeking.  *
What is total monthly income of your household? *
What is the total cash on hand/savings for your household? *
What is the total monthly rent or mortgage your household pays? *
  What is the total monthly utility/telephone/internet cost that your household pays?  
 *
List each member of your household using the following format: name/relationship to you/DOB/sex *
Including yourself, please list anyone in your household who is not a US citizen. *
Are you currently employed? *
Required
Please provide your employer's name if applicable. *
How long have you worked for this employer? *
Required
If you have worked for this employer for less than 1 year please share how long you have been employed. *
In your own words please describe your current need for assistance and the challenges preventing you from meeting these needs. *
If awarded, please share how the Shepherd's Tent Emergency Relief Grant would make a difference to you situation. *
Do you consent to being contacted during the review of your application should it become necessary? *
Required
Please acknowledge that you understand the following:
 You will be required to submit a copy of the bill(s) you are applying for assistance with.
Please acknowledge that you understand the following:
 Any assistance awarded will paid directly to the service provider.
Please acknowledge that you understand the following:  You alone will be responsible for providing any payment information needed to an assigned Shepherd's Tent case manager.
Is there anyone belonging to your household that could benefit from additional mental health and/or substance abuse services? *
Required
Please confirm that the information provided is accurate and complete *
Required
By  electronically  signing this application I am consenting to the review of the information provided. If award I will be informed and the disbursement of said grant would be issued as a direct payment. *
Required
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