Application for Financial Assistance
Rainey’s Light is a 501(c)(3) non-profit charity designed to help parents in recovery who have young children. Please complete the questions below to the best of your ability and then hit the submit button at the bottom of the form. If you are unable to complete and submit the form, please call (717) 576-0899 to apply by telephone. This information will be used to determine if you qualify for any of our services. We will not share your personal information with anyone without your permission.
Name of Applicant *
Your answer
Gender *
Required
Date of Birth *
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Race *
Your answer
Phone *
Your answer
Email *
Your answer
Current Address *
Your answer
Name of Co-Applicant
Your answer
Gender
Date of Birth
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YYYY
Race
Your answer
Co-Applicant's Current Address
Your answer
Emergency Contact Name, Address and Phone *
Your answer
Children's Name(s), Age(s), Grade(s) *
Your answer
Do you have custody of the child(ren) listed above? *
What is your "clean date" or how long have you currently been clean from drugs/alcohol? *
Your answer
Are you currently in in-patient rehabilitation? *
If yes, what is your length of stay and anticipated completion date?
Your answer
If no, please describe your rehabilitation/recovery?
Your answer
List drug(s) used *
Your answer
What is your future recovery plan? *
Your answer
Do you have a criminal record or pending charges? *
If yes, please explain.
Your answer
Employment Status *
Your answer
Last Grade Completed (include college, if any) *
Your answer
Are you receiving any type of financial assistance? *
If yes, please explain.
Your answer
Amount you are requesting from Rainey's Light? *
Your answer
Purpose of Request? *
Your answer
Date Needed By *
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Payee Information (name, address, phone, email, website) *
Your answer
Describe your financial need in detail. *
Your answer
List a professional person such as caseworker, probation officer, etc., who can provide a reference for you and your commitment to long-term recovery (name, agency, phone number). ****** (Please contact them and give them permission to release your information to us). *
Your answer
Verification Statement
I verify that the facts contained in this application are true and correct to the best of my knowledge, information and belief. I understand that Rainey’s Light is not liable for any damages of any kind resulting from the granting of this application. I understand that, if approved, Rainey’s Light will send or give payment directly to the payee. I understand that Rainey’s Light may deny my application if it does not meet their criteria, due to lack of funding, or if it is discovered that I was not truthful. I understand that if I am denied, I will be able to reapply if the circumstances for denial change. Any and all questions should be directed to Michele Avery, President of Rainey’s Light at (717) 576-0899, raineyslight@yahoo.com.

If you agree to this information, please type your name and the last 4 digits of your social security number below and submit electronically.
Electronic Signature *
Once you have completed the application above, please type your name and the last 4 digits of your social security number below to confirm your identity and then submit electronically. You will hear back from a Rainey's Light volunteer within two weeks.
Your answer
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