Assistance Request Form

By submitting this form you indicate your voluntary consent for Kelsey Creek Church to share any and all information contained in this application (including any other material(s) you have provided to support your request) with its partner churches, as they deem necessary in order to reasonably verify, coordinate, and respond to your request for assistance, as well as to determine the extent, legitimacy and duration of your need. I certify that the information I have given in this application is true and correct to the best of my knowledge, and I authorize verification of my circumstances.