Harbins Community Baptist Church - Family Charity Program Request Form

First Name

Last Name

Date of Birth (mm/dd/yyyy)

Sex

Address 1

Address 2

Country

City

State

Zip/Postal Code

Email

Phone Number

Preferred Method of Contact
Email
Phone

Do you still live at home or under the care of a guardian?

Are you a church member at Harbins?

Place of employment & job title (if applicable)

Employment address 1

Address 2

Country

City

State

Zip/Postal Code

Length of Employment

Supervisor's First Name

Supervisor's Last Name

Supervisor's Phone Number

If any other household members are working, please list their job title, company, and address
Name - Job Title, Company (Street, City, State, Zip Code)

If applicable, please state reason for present unemployment status

Have you requested assistance from any other agency in the past 12 months?

If applicable, please list the names of agencies and dates of assistance received from other organizations within the last 12 months

If applicable, please give date(s) and amount(s) of past assistance received from Harbins

Please check whether you have received any of the following forms of assistance within the past 12 months
Food Stamps
W.I.C.
Georgia PeachCare for Kids
Georgia Medicaid/Medicare
Other

FINANCIAL INFORMATION (FOR ONE MONTH)

Total household income

Extra income or financial assistance?
Including but not limited to: Ailmony/Child-support; Federal Assistance (e.g. Social Security); State Assistance (e.g., Unemployment); Insurance (Disability; Workman's Comp); Other (family support)

Mortgage / Rent
Please specify which one: (Enter the following: Morgage: $##.## or Rent: $##.##)

Total Household Utilities
Including but not limited to: gas, water, garbage, electricity, phone, cable, internet

Car Payment / Insurance

Are you currently pregnant?

Please list the name, age, gender, and relationship to you of each child for which you are requesting family & baby care.
Examples: John Doe, 3 months, boy, son; Jane Doe, 2 years, girl, granddaughter

What specific family and baby supplies would benefit your family?
We will respond to your request based upon this answer. At any time, we have may baby formula, diapers, bottles, and other supplies. If you are looking for baby clothes, please include sizes and gender. If you are looking for diapers, please note the requested diaper size. Our inventory is based upon charitable donations; we cannot promise any specific items at any time.

Is there any other information we should know?

FAMILY & BABY CARE STATEMENT

Thank you for letting us have the ability to support your family and baby. We understand that all of life is a gift from God. God knows the name of your child and God cares about your family. We will do our best to provide any care of support that we can for your family. Requests for financial assistance are prayerfully reviewed by our Elders and/or Financial Stewardship Team. We reserve the right to deny assistance for any reason. We can only offer assistance based upon the amount of designated “benevolence” money we receive. Applicants for financial assistance will be notified of the assistance that will be provided, and when the funds will be available. HCBC does not make checks payable directly to the individual(s) requesting assistance. HCBC does not overnight payments.

We may be limited in the services and supplies that we can provide at any given time. We may provide care by putting you in contact with other organizations who are better equipped to offer care for expectant families. At Harbins, we will offer a community willing to walk with you through this pregnancy and support you at different steps along the way.

Please know that Harbins Community Baptist Church is only a recipient of donated goods. Our ministry does not include a shelter or kitchen and we rely upon volunteers from our church to serve our community. While we hope to share quality goods with you and your family, every recipient of donated goods waives any right to file charges against Harbins Community Baptist Church or any members due to the misuse of products received herein or problems related to the products received at Harbins Community Baptist Church. Also, every recipient of donated goods agrees to use these products for his or her family, not to repurpose these products for financial gain. By signing below, you are agreeing to use these products in good faith, exercising discernment in potential faulty products or pursuing the necessary information for the proper use of these products.

By signing your name below, you are affirming that the above information is true, to the best of your knowledge.

Date (mm/dd/yyyy)

DIGITAL SIGNATURE
Full Name

Would you be interested in being added to our non-member email list?
Through this list, you can keep up with events and news from Harbins Community Baptist Church.

Family Charity Program Request Form

We'd love to hear from you. Fill out the form below to get started.

FINANCIAL INFORMATION (FOR ONE MONTH)

FAMILY & BABY CARE STATEMENT