Holiday Helper Application - KM Johnson Davis

KM Davis Ministries provides short-term emergency assistance to improve life situations. To start the process of receiving services, please fill out the following pre-screening application to help match you with the program(s) that will best fit your need. Assistance and referrals are subject to program eligibility and availability. The entire form should take 5-10 minutes to complete. After filling out the application, it will take 3-5 business days for a team member to reach out to you with the contact information you provide. For questions or assistance filling out the form, please email the KM Davis Ministries Team at hello@kmjohnsondavis.com. *

Yes, I understand.

What city do you live in? *

What county do you live in? *

Do you have children attending school? *

Yes
No

Were you referred by anyone? *

Yes
No

Program Selection *

Christmas
Thanksgiving

Name *

First

Last

Preferred Name *

What is your current living situation? *

Street Address *

City *

State *

Zip Code *

Phone Type *

Cell
Home
Work
Do not have a phone number

Phone

Email Type *

Personal
Work
Alternate
Do not have an email address

Primary Email

Gender *

What is your preferred language? *

Ethnicity *

Race *

Birth Date (mm/dd/yyyy) *

How many people live in your household? *

Please provide the names, birthdate, gender and relation of all household members.

Please check the benefits that your household is currently receiving. *

What type of income does your household receive? *

Have you been assisted by another agency? *

Yes
No

If yes to above question, please list here.

Is there anything you would like to add? Please add any comments or questions you might have.

I hereby authorize the release of information to KM Davis Ministries (KMDM) to receive the assistance, I am requesting. I further certify that the information I have stated is true and correct and that all income is reported. I understand KMDM may verify the information on this application and that deliberate misrepresentation of information may subject me to denial of assistance/services. I give permission for KMDM to discuss my case with other agencies, government entities, businesses churches, attorneys, organizations, societies, hospitals, medical personnel, individuals, and any others deemed necessary to verify application information and/or identify additional sources of assistance. I understand that all information is treated as confidential information by KMDM. In consideration of the opportunity afforded me by KMDM, I hereby agree that I, my assignees, heirs, guardians, and legal representatives, will not make a claim against Metrocrest, or any of its affiliated organizations, or any of their board of directors collectively or individually, or the supplier of any materials or equipment that is used by KMDM, or any of the volunteer workers, for the injury or death of myself or damage to my property, however caused, arising from my participation with KMDM. Without limiting the generality of the foregoing, I hereby waive and release any rights, actions, or causes of action resulting from personal injury or death to myself, or damage to my property, sustained in connection with my participation in any program of KMDM. I have read, understood, and agree to the policies described above as they relate to services provided by KMDM. *

I agree with the organization’s policy

Please type your name below to accept the terms above and sign the form. *