“She opens her arms to the poor and extends her hands to the needy.”

Do you or do you know someone that may need assistance with utilities, groceries, home repairs, car repairs, yard work, furniture, clothing, medical services provided by Mira Direct Primary Care, dental services provided by Minden Family Dental, or prayer requests, please fill out the form below. Thank you so much and God bless.

Contact Form

Name

Date

Street Address

City

Zip

Phone

Email Address

Number of Kids Living with you

Ages of kids

Current Employment

What Type of Assistance are you Needing?

Check If You Understand Check If You Understand Please allow up to 7 days for your request to be processed.*

Initials

Do you have a relationship with Christ Jesus? Do you have a relationship with Christ Jesus? Yes No Unsure

Would you like more information about having a relationship with Christ Jesus? Would you like more information about having a relationship with Christ Jesus? Yes No

Are you member of a church? Are you member of a church? Yes No

Where do you attend church?

6 + 7 =

I certify that my answers are true and complete to the best of my knowledge.

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WEBSITE DESIGNED AND DEVELOPED BY SUMMITEER CREATIVE

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WEBSITE DESIGNED AND DEVELOPED BY SUMMITEER CREATIVE