COVID-19 KBC Assistance Request Form • Kahului Baptist Church

Are you currently sick or have you recently been around someone who is sick or diagnosed with COVID-19? *

Yes

No

Reduced income AND/OR loss of employment due to COVID-19? *

Yes

No

How soon do you need the assistance? *

First Name *

Last Name *

Home Address *

Home Address Line 2

Home City *

Home Zip Code *

Home State *

Phone Number *

Email Address *

Church you attend: *

Are you a member of that church? *

Yes

No

Your pastor's name & phone number (if not a member of Kahului Baptist Church):

Type/nature of need requested & amount: (i.e. bill pay, gift card for household needs, rent assistance, other)

If requesting food/grocery/household items, please indicate preferred store: *

First time receiving aid due to the impact of COVID-19 from Kahului Baptist Church? *

Yes

No

Have you received other financial assistance? *

Yes

No

If you responded "Yes", please list where you received financial assistance from and what type of assistance you received: *