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Your name
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Last name
Email address
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Phone number
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Address
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Birthdate
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Date
Gender
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Household members
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Is Coastline Church your home church?
Yes
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Please describe your financial situation?
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I need one-time assistance
I need short-term help (3-months max)
I need long-term help (6-months max)
Are you currently employed?
*
Yes
No
Name of employer
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Have you applied for assistance before?
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First Time
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How can we assist you?
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Please share the reason and circumstances for why you need assistance at this time.
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