Cleaning Closet Application
Please fill out the form completely. Apps are due by 4:30 pm, the 2nd Tuesday of the month you’re applying for. Supplies are limited, items may vary from what you sign up for.
Is this the first time you’ve applied for Cleaning Closet Assistance? *
Month You are Applying For *
Please select the month of the next distribution day. (Distribution days are on the 2nd Wednesday of each month.)
Name of Head of Household (Last, First) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Number of People Who Live in Household *
Names & Birthdays of Other Person(s) Living in Household
Your answer
Address (street, city, state, zip) *
Your answer
Phone *
Your answer
Email
Your answer
Current Assistance Received *
Required
Home Church (if you have one please list it under "Other") *
Please let us know what CLEANING PRODUCTS you need. Understand that supplies are limited and you may not receive exactly what you’ve asked for. Please check only what supplies you need. *
Yes
No
Laundry Detergent
Dish Soap
Toilet Paper
Paper Towels
General Cleaner
Window Cleaner
Bathroom Cleaner
Dish Sponge
Hand Soap
Please let us know what HYGIENE PRODUCTS you need. Understand supplies are limited and you may not receive exactly what you’ve asked for. Please check only what you need. *
Yes
No
Shampoo
Conditioner
Body Soap
Toothbrush
Toothpaste
Deodorant
Employment Status *
If employed, where?
Your answer
Will you be able to stay for dinner at 5:00 PM? (If so, how many will be eating?) *
We'd love to have you stay and eat with us. There's no cost.
What are some other ways we could help you?
Your answer
Prayer Request(s)
Your answer
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