Martindale Brightwood Assistance Request                      
The Edna Martin Christian Center is here to serve residents in Martindale Brightwood and the surrounding area.  The following questions must be filled out completely so that we can consider your request for assistance.  

PLEASE NOTE:  

1) Requests will be filled based on eligibility and in a first-come, first-served manner.  

2) Requests will be processed within 14-21 business days after receiving your request.
  
3) IF YOU HAVE RECEIVED AN EVICTION NOTICE OR A DISCONNECT NOTICE FOR YOUR UTILITIES, PLEASE INDICATE IN THE FORM BELOW.

4) Submitting an application is not a guarantee of assistance.  Each request is subject to the applicant's eligibility and funding availability.
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Please note:  if you are in need of food from our food pantry, there is no need to complete this form.  

Instead, please visit us Monday through Friday from 1:00pm-3:00pm at 2605 E 25th Street.  Food pantry service is limited to one visit per week per family.  Please bring a valid photo ID.  

For all other needs, please fill out the following information:
BASIC INFORMATION
First Name *
Last Name *
Street Address *
Zipcode  (Please note: If your zipcode DOES NOT appear below, please call 211 to be referred for assistance closer to your home.) *
Preferred Phone Number *
Email (if no email, type N/A) *
Date of Birth *
MM
/
DD
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YYYY
Gender *
Race *
Ethnicity *
Marital Status *
Employment Status *
Highest Grade Level Achieved *
In the past 12 months how much money has your household earned? *
How many people live in your household (including children)? *
Have you received an eviction notice from your landlord?
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Have you received a disconnect notice from your utility company?
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