FORM INSTRUCTIONS: Please fill out application completely and thoroughly. Leaving out information will cause a delay in your application process.
All items with an asterisk (*) are required to be filled out before form can be submitted.
OUR PROGRAM CANNOT HELP WITH EMERGENCY NEEDS OR PAYMENT OF BILLS - THIS INCLUDES RENT, UTILITIES, CAR PAYMENTS, MEDICAL BILLS, ETC.
APPLICATION PROCESSING TIMES VARY, AND USUALLY TAKE 1-3 WEEKS DEPENDING ON THE REQUEST DUE TO PROCESSING TIME.
THANK YOU FOR YOUR PATIENCE!
To download a PDF version of the application to mail or fax in, click here. (online application is preferred)
Need A Break Services Gift Application
This gift program aims to assist with one-time needs that will make a meaningful difference for someone who is otherwise able to maintain stability.