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ONLINE APPLICATION FOR SERVICES
EMERGENCY RELIEF / VEHICLE REPAIR PROGRAMS

Simply complete this form here and we will get back to you within 48 hours of submission. Thanks!

The Compassionate Connections Center offers programs and assistance services to individuals residing within the Clintonville School District or to qualifying individuals by referral. Services offered by the Compassionate Connections Center are subject to change at any time. Please allow 48 hours for application processing.

PERSONAL INFORMATION

First name

Last name

Address

Age

Phone

Email

HOUSING DETAILS

Household Size

Additional Household Members (If Applicable)

First Name

First Name

First Name

First Name

Last Name

Last Name

Last Name

Last Name

Age

Age

Age

Age

PROGRAMS AND SERVICES OF INTEREST

I/We are interested in following services:

Emergency Funds

Car Repair

Provide a copy of the following:
- Copy of Bill
- Paystubs/Benefit Award Letter
- Bank Statements

Upload File

Provide a copy of the following:
- Estimate of Repairs
- Proof of vehicle ownership
- Paystubs/Benefit Award Letter
- Bank Statements

Upload File

Alternate Contact

First Name

Last Name

Phone

Note to Applicants: If any information on this application is found to be false or incomplete, such finding may be grounds for denial of requested assistance and may be a basis for debarment from participation in all Compassionate Connections Center Inc Programs.

Inappropriate behavior such as profanity, verbal abuse of staff or any other disruptive behavior is prohibited. Any such behavior may result in the suspension or termination of your privileges at The Compassion Connections Center.

I accept terms & conditions

Your Signature

PLEASE NOTE: Your application will be considered incomplete until all required documents have been submitted.

Thank you! We'll be in touch within 48 hours of submission.

The Compassionate Connections Center Inc. is proud to be an Equal Employment Opportunity and Affirmative Action Organization. We celebrate diversity and do not discriminate based on race, religion, color, national origin, sex, sexual orientation, age, veteran status, disability status, or any other applicable characteristics protected by law.

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