HELP for all PEOPLE

APPLICATION PAGE

INSTRUCTIONS

INSTRUCTIONS: Copy and paste this application to your email system and fill in all the blanks. Do not worry how long your answer is. It is a word program and will fix the length of the answer so no question or answer will be lost. Send the filled out email to helpforallpeople@bellsouth.net. You will get either a phone call or email within 72 hours depending on my health. The rest is up to the community. I make NO promise that I can get you help only that I will try my best to do what I can. I will contact all the sponsors I know an reach out to those I don't and ask on your behalf. The rest is up to Faith. Good luck, Catherine

Questionaire

NAME:_________________________PHONE:_________________________WORK PHONE:_____________
EMAIL:_________________________FAX:_________________________________
ADDRESS:______________________CITY:___________________________STATE:_________________ZIP:_____________________
DOB:___________________________SS#:____________________________
SPOUSE:_______________________DOB:____________________________SS#:_______________________
CHILDREN:___YES___NO AGES :__________________________
OCCUPATION:____________________________
STATUS:______MARRIED___DIVORCED_____SINGLE______WIDOWED
EMERGENCY CONTACT:_________________________________________
PLACE OF EMPLOYMENT:_______________________________________
WHY ARE YOU NOT WORKING?___________________________________________________________________________________
ARE YOU ON WORKER’S COMP?__________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________


PERSONAL REFERENCES: YEARS KNOWN & PHONE# PLEASE THIS IS A MUST
1.______________________________________________________________________________________________________________
2.______________________________________________________________________________________________________________
3.______________________________________________________________________________________________________________
add any extra names of friends or family, church members, anyone that can relate to your current problems.
a.______________________________________________________________________________________________________________
b.______________________________________________________________________________________________________________
c.______________________________________________________________________________________________________________
d.______________________________________________________________________________________________________________
e.______________________________________________________________________________________________________________
commments ______________________________________________________________________________________________________
________________________________________________________________________________________________________________
1. What are you/and or your spouses health problems? _____________________________________________________________________
2. Are the above health problems recent?__________________________________________________________________________
2A. Or are they newly diagnosed?________________________________________________________________________________
3. Are you/and or your spouse’s health problems the reason for emergency need for help?_______________________________________
4. Do you/and or your spouse currently use any drugs?____________________ Alcohol?___ Other?__________________________________
5. Do you/and or your spouse have any kind of addiction?__Yes ___NO
6. Did you/ and or your spouse have any kind of addiction in the past?___________________
7. Have you/ and or your spouse ever been charged with a felony or misdemeanor, other than a minor traffic or parking violation?_______________
________________________________________________________________________________________________________
8. Have you/ and or your spouse ever had a restraining order entered against you?_____________________________________________
9. Have you/ and or your spouse ever been involved in any type of litigation? Litigation- lawsuit_________________________________
10. Do you/and or your spouse belong to any affiliations or organizations? No
11. What are your/and or your families favorite things to do (activities)? Sports?___Hand crafts?_ Internet? Biking?___Hiking? Other?______
12. What qualities do others admire in you?____________________________________________________
12 a) What qualities do others admire in your spouse/and or family?
13. How would most people describe you?__________________________________________________________
13aYour spouse/ and or family?_________________________________________________________
14. How would you describe yourself?_____________________________________________________________________________
15. What do you think is your best quality?______________________________________________________________________
16. Do you have any current or on going medical insurance?___Yes No
17. Are you in need of help medically?_______________________________________________________________________
18. Do you or any member of your family in need of urgent medical care?__YES _ NO But, unable to pay?___YES___NO
18a Please detail in full ________________________________________________________________________________________
19. Do you(person filling out application) feel you have a problem that nobody will listen to? ___________________________________
*****Sometimes our families are the last person you want to talk to or ask for help, been there done that. Sometimes we have mental health problems, or gender identity issues they have yet to tell anyone about. Sometimes we feel like the world is crashing around us and we want to sleep and NEVER wake up ever again. Unload your burden here, I will listen and together we will find a way to meet your need.______________________________
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
20. Is the problem a mental health concern?___YES NO Seeing things?_______________Hearing things?
21. Are you sad all the time?___________________________________
22. Are you the person with the health problem, being seen by SOME KIND of a doctor? _______________________
23. Are you and or a family member in need of medication you can’t pay for?__________________________________________________
24. Do you and or your spouse receive any kind of Federal Assistance? YES___NO How much?_______For how many people?_________
Such as Aide to Families With Dependent Children (AFDC or ADC), Public Assistance, Social l Security Supplemental Income, Railroad Retirement, etc.....?Please explain:___________________________________________________________________________
25. Does your family receive Food Stamps? YES__NO For how many people? Amount?_____Monthly?___
26. Do you/ and or your spouse receive Child Support?____ YES NO How much?_________When?___weekly___bi-weekly_____monthly
27. When was the last time you received a Child Support payment?______________________________How far is your child support behind?_____
28. How much Child Support is owed to you/and or your spouse?________How many months?______years?__________ Do you have any idea where the parent that owes the support is and are you willing to give information to find him?______________________________________
****FUN FACT ABOUT CHILD SUPPORT: If Child Support is still due to the child at the age of 18, then the 18 year old is then able to file their own lawsuit against the non-paying parent. The Child Support goes from being Child Support to Personal Injury, on the grounds that the child could have had a better life if the "Original Child Support Order" had been paid. But take a warning also, your child can turn around and sue the parent that raised them. Yes, if you, in DECIDE, your mind YOU didn’t want the fathers help for whatever reason, they could prove neglect. Call me for more details. you can get Child Support until the Child finishes college. In most cases that is, but if your child is a med student or going to law school that support could go until they finish all their studies!
29. Is there a court order for Child Support?______________________________________________________________
30. Do you feel you and your mate have an abusive relationship?_________________________Explain please______________________________
31. Explain what you feel is the emergency at this moment? _____________________________
____________________________________________________________________________________________
33. So, how have you been getting along until now?__________________________________________________________________________
34. If you are helped by someone sponsoring a ONE TIME PAYMENT of your mortgage, rent, car payment, gas or electric; what is you plan for next month?__________________________________________________________________________________________
35. How can we work together so six months from now you are not in the same place of emergency as you are today? Please answer in detail _______
___________________________________________________________________________________________________________
36. What local Agency’s have you already contacted?____________________________________________________________________
37. What Agency has helped pay your bills ______________________________________________________________________
38. Which ones did the help pay?_________________________________________________________________________________________
39. Which bills are still in need of payment?____________________________________________________________________________
40. If you had to pick only one bill that had to be paid, which bill would you want paid?________________________________ Why?_____________ How much is this bill?__________________________ How far behind is this bill?___________________________________
41. Are you involved I any legal action?(Have any trails or lawsuits against you coming up?)__________________________________________
42. Our pets are the last thing we worry about. Do you and your family have Pets? YES__NO
How many? Dogs Cats__Birds__Horses Fish_Snake_Other_________________________
43. Do they have any health problems?__YES ___ NO (your pets lol)
They are like children they need regular check-ups and shots too.
44. Do they need to be spay or neutered? YES NO
45. Other than money, what do you feel could help you out of you problem right now? Please use as much paper and details as you need to explain your current emergency.___________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
46. Is there anything you need to say or comment about, or ask that is not in the questionnaire?___________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

Release Form

Now about this release form. Please type in your name and email the entire application. Once you have emailed the application I will send you a address to send a Paper Copy of the entire application with your signature written and printed and dated. This is for every one's protection, yours and mine. I MUST have your had written signature on file.
RELEASE FORM
I acknowledge that I have filled out this form with all the correct information and hold it to be true at the time of my signing. I also understand that all the above information will be verified before any arrangements to help me will be made. Should any of the information prove to be falsified after assistance has been rendered on my and or my families behalf I will make arrangements with my sponsor to repay all monies rendered to help in my time of need.
With the signing of this application I acknowledge that I am giving HELP for all PEOPLE the right to talk to all the persons named and unnamed on this application. I know that HELP for all PEOPLE may need to talk a variety of people to aide in my emergency needs..
I also acknowledge that I have read and answered all the above questions, that I understand, and have the legal approval for, and agree to the terms and conditions in connection with all answers concerning myself and members of my family. I permit a copy of this consent to be used in place of the original for purposes of gaining help for mine and my family needs.
I acknowledge that neither myself or anyone in my family will NOT bring any action against anyone Catherine Cunningham or anyone she finds to help in our time of need.
You will however give the above mentioned peoples the unconditional rights to use your finished story to inspire others to join in doing "Random Acts of Kindness for others".
This form has been fully explained to me, and I am satisfied that I understand its content and significance. Once this application has been received by HELP for all PEOPLE by email a conformation phone call will give me the address to send in my signed application. Then and only then will sponsors be called to help in my needs. Signed Applications MUST be on file with the RELEASE before work can begin.
_______________________________________________________
your signature date
_________________________________________________________
printed name date
__________________________________________________________
NOTARY AND SEAL AND

Email us
helpforallpeople@bellsouth.net