Name
*
First Name
Last Name
Address
*
Please state your full address below, including your postcode
Email
*
Marital status
Single
Married
Number of dependents
1
2
3
4+
Total number of people in household
1
2
3
4
5+
Number of working adults in household
1
2
3
4+
Employment status
Currently employed, full time
Currently employed, part time
Currently unemployed, as a result of COVID-19
Currently unemployed, none COVID-19 related
Name of employer
If married, is your spouse currently employed?
N/A
Currently employed, full time
Currently employed, part time
Currently unemployed, as a result of COVID-19
Currently unemployed, none COVID-19 related
Are you a member of NTCG Chrisma Christian Centre?
Yes
No
If yes, please select which best describes your attendance at Chrisma Christian Centre
Frequent (every week)
Seldom (special events)
Occasionally
in your opinion which best describes your financial situation?
Short term emergency
Short term problem
Long term problem
The total amount of your request is
What is this amount for?
Please detail why and how you wish to use the amount requested above
Are you willing to receive or be referred for financial counselling?
Yes
No
Total household weekly income
Are you receiving any other means of financial support?
Please detail support below or state N/A if not applicable.
Briefly explain your needs and what led you to seek assistance. We will be praying for you and providing counsel where needed.
By ticking this box I confirm that I am happy for my details provided above to be used in the consideration of my Chrisma Care Fund application and future correspondence from the Chrisma Christian Centre Care Fund team.
*
To allow us to progress your application please tick the box below.
