Gender Select one Male Female Please list your specific request: What event(s) lead to needing assistance? Do you live within a 3 mile radius of UPC? Select one Yes No How did you get connected to UPC? From whom have you received assistance in the last six months? Family/Friends Churches Agencies Do you attend church regularly? Select one N/A Occasionally Weekly Are you employed? Select one Yes No Are you willing to meet someone on a Sunday morning about this? Select one Yes No Are you able and willing to contribute your resources to meet this particular need? Select one Yes No How can we come alongside and support you? I want to learn or improve my English. I am looking for an after-school activity/tutoring for my child/children. I am suffering the loss of a loved one or friend. I am struggling financially and need help budgeting. I have an urgent need for financial assistance. I have an urgent need for food assistance. I am struggling in my marriage and/or parenting. I would like someone to talk to. I need healing from sexual abuse. I feel stuck in life. Are you interested in knowing about the following? UPC and our Worship Service Relationship with God Understanding the Bible Talk with a Pastor I authorize UPC to verify any information provided and share information with other churches or agencies in order to help have my needs be met. - Type your digital signature below.