Radiant Church - Hurricane Assistance Form

Please fill out the form below to let us know how we can assist with your needs, and we will reach out to you as soon as possible.

1. Personal Contact Information

First Name

Last Name

Email

Phone Number

Preferred Method of Contact

Phone

Email

Text

Are you currently a member (or regular attender) of Radiant Church?

Yes

No

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2. Household Information

Home Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Number of People in Household

Names of Additional Household Members (including children)

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3. Needs

Details of Need

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4a. Other Forms of Assistance

Have You Applied for Any Other Forms of Assistance?

Yes

No

Types of Assistance Includes:
FEMA, Red Cross, Local/State/Federal Aid, Insurance Claims, Etc.

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4b. Other Forms of Assistance

Assisting Organization

Status

Applied

Approved

Denied

Details

If you've applied for additional aid, please click "Add Another Type of Assistance" below. Otherwise, click "Next".

5. Eligibility for Other Forms of Assistance

Are You Currently Eligible for Any Other Forms of Assistance?

FEMA

Red Cross

Local Government (Buncombe / another DSS)

State/Federal Aid (other than FEMA)

Insurance

Other:

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6. Additional Details / Authorization

Additional Information or Special Requests

Do You Give Consent to Share Your Information with Other Organizations Providing Assistance?

Yes

No

Signature

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Hurricane Assistance ApplicaTION

Service Times

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