New Client Form - Wylie Christian Care Center
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Name: Last, First*
Date of Birth*
Gender
Male
Female
Street Address*
City*
-
Copeville
Josephine
Lavon
Lucas
Nevada
Royse City
Sachse
St. Paul
Wylie
Phone:
E-mail
Driver's LIC/ID #
Issuing State:
Employer
Number of Family Members Living With You:*
List Adults Name and Age Living With You:
For Financial Aid fill out the next two sections. Make sure you indicate which rent or utility bill you need paid.
Income Source (Dollars per Month , Net Take-Home)
Employment Net Pay $
Food Stamps $
Net from Social Security $
SSI $
Other $
Expenses (Dollars per Month)
Housing (Rent)$
Utilities (Gas, water, elect)$
Car Payment $
Child Care $
Other (Medical, etc) $
Brief Reason You Need Help:
Bill you need help with (i.e. Rent, Elect, Gas)
Agreement*
I acknowledge that the Wylie Community Christian Care center is a charitable, non-profit organization and I waive all rights, both for myself and the persons shown above, to seek damages for any act on behalf of the agents of the center, whether such act or omission is negligent or willful, regardless of cause, which may occur. I also agree to grant permission to share this information with other organizations to better serve me and my needs.
I agree
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