Your Name (required)

Your Email (required)

Address (required)

Phone number (required)

What is your family composition?
SingleMarriedSeparated/DivorcedWidowed

How many children?

How many adults?

Would you like to remain anonymous?
YesNo

Do you live on the ground floor?
YesNo

If no, is there an elevator?

If there is an elevator, what are the internal dimensions?

Are there narrow or unusual hallways and stairwells?
YesNo

Please list your needs:

Do you attend HCC on a regular basis?
Once a weekOnce a month

Have you attended a HCC new members orientation?
YesNo

List ministries, if any, that you are involved in at HCC:

Do you consistently give Tithes/Offerings to God thru HCC from your family income?
YesNo

Have you received financial assistance from HCC in the past 24 months?
YesNo

If yes, please explain:

Describe briefly what has caused this need to arise:

Have you called family or any other churches or organizations for assistance/help? If so, who, and how
much assistance have they offered?

Do you attend a HCC Connection Group?
YesNo

If so, which one?

In taking this gift, I agree to RELEASE AND HOLD HARMLESS AND INDEMNIFY Hill Country Faith Ministries, its Board of Directors, all their agents, servants, volunteers, and employees from any liability, claims, demands, and causes of action arising out of or relating to any loss, damage or injury sustained in connection with or arising out of accepting this donation.

Signature:

Although we can usually respond to your request the same day, please allow up to 48 hours to receive an email
response or call back.