Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Today's DateGenderHome PhoneAddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDo you attend WHC?YesNoAre you a member of WHC?YesNoHow long have been attending?Are you married?YesNoIs your spouse a member?YesNoN/AMember Since?Do you attend WHC Small Group Meetings?YesNoAre you currently serving in a ministry at WHC?YesNoWhat area?Do you regularly attend at least one church service per week at WHC?YesNoDo you consistently tithe 10% of your income to WHC?YesNoHave you ever received benevolence from WHC before?YesNoIf applied for benevolence at WHC, were you ever declined?YesNoIf you have been declined for benevolence from WHC before, please provide a reason and date below:Have you spoken with a WHC leader about this need?YesNoIf yes, Leader’s Full Name:Did someone from WHC refer you?YesNoDescribe what has caused this need to arise?Is there a deadline for this need to be met?YesNoWhat is the deadline?Bill #1 (description)Amount of bill #1Number OnlyBill #2 (description)Amount of bill #2Number OnlyAmount RequestedNumber OnlyYour Current or Former employer:Are you presently unemployed?YesNoAre you drawing unemployment?YesNoHow many children are living in the home?Number OnlySignatureClear SignatureNameSubmit
