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Resident Assistance Request
Resident Assistance Request
Golden Cross Senior Ministries
(
Please complete entire form
)
Community Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Requested By
(Required)
Requestor's Email Address
(Required)
Position
(Required)
Name of Resident
(Required)
Address or Apt#
(Required)
How long have they been a resident?
(Required)
Date items are needed:
(Required)
MM slash DD slash YYYY
Homeless Resident (according to Wesley Living guidelines)
(Required)
Yes
No
Is the resident noted as “HOMELESS” in the Wesley Living database?
(Required)
Yes
No
Choose Need(s):
(Required)
Furniture
Move-In Kit
Personal Needs
Background information - Please list ALL information pertaining to the need
(Required)
What steps have been taken to determine the inability for the resident, family, friends and/or outside resources to assist/provide the needed items?
(Required)
Funds Disbursement Information:
(Required)
Pick up from GCSM Office
Pick up from Local Store
Order online and sent to community
Division Head (Regional Asset Manager)
(Required)
Kelle Heathcott
Brandi Williams
Jeremy Speed
Date
MM slash DD slash YYYY