Cleveland Chesed Center Application Form

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Thank you for reaching out the Cleveland Chesed Center. Please answer the following questions to help us determine your eligibility for services.

Today's date

YYYY

Last Name *

First Name *

Street Address *

City *

Zip *

Phone number *

E-mail Address *

How did you hear about the Cleveland Chesed Center? (Please provide the name of the person or organization who referred you, if applicable) *

Number of family members living at home *

Are you currently employed? (check all that apply) *

Yes

Under-employed

Looking for a job

Other:

Required

Is your spouse currently employed? (check all that apply) *

Yes

Under-employed

Looking for a job

Not applicable

Other:

Required

What is your annual household income? *

Are you affiliated with a synagogue? *

Yes

If yes, which one?

Are you currently receiving any other assistance? (Check all that apply) *

Medicaid for yourself and/or your spouse

Medicaid for your children

Medicare

Food Stamps

WIC

HUD

Unemployment

Other government assistance programs

Financial assistance from an organization

Financial assistance from family/friends

None of the above

Other:

Required

What services are you looking to receive from our agency or one of our partner agencies?

Food and Household necessities

Clothing

Assistance applying for government programs

Job placement

Job training/readiness

Mental Health

Case Management

Personal finance/household budgeting

Other:

Please describe in brief any particular circumstances that have led you to reach out for assistance. (i.e. outstanding school loans, high insurance premiums, recent loss of employment, etc.) *

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