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Hurricane Assistance ApplicaTION
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
1 / 6
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)
2 / 6
3. Needs
Type of Assistance Needed (check all that apply)
Food
Temporary Shelter
Home Repairs
Clothing
Financial Assistance
Emotional/Spiritual Support
Other (Please Specify Below)
Details of Need
3 / 6
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.
4 / 6
4b.
Other Forms of Assistance
Assisting Organization
FEMA Assistance
Red Cross
Local Government Aid (Buncombe / another DSS)
State/Federal Aid (other than FEMA)
Insurance Claims
Other Charitable Organizations
Other (please specify in the details)
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:
5 / 6
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
6 / 6
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