Crisis Ministry Intake Form

The PRMBC Crisis Ministry offers financial assistance to Pilgrim Rest members and non members who live in the following zip codes:

75203, 75204, 75205, 75207, 75208

75209, 75210, 75212, 75214, 75215

75219, 75223, 75225, 75226, 75235

75246, 75247, 75390

If you are a Pilgrim Rest member or live in one of the above mentioned zip codes, you may complete the Crisis Ministry Intake Form below to request assistance. If a question does not apply to you, please enter N/A. Note: You will receive a confirmation email with instructions to complete your application. All requested documents are required at the time the application is submitted. Incomplete applications will not be processed. Click here to view the list of required supporting documents and view, download and sign the Crisis Center disclaimer.

Food distribution is held the second Thursday of each month at the PRMBC Crisis Center.

Applicant Information

* First Name

* Last Name

* Date of Birth

* Sex

Female Male

* Email Address

* Home Phone Number

* Cell Phone Number

* Address

* City

* Zip Code

Employment Information

* Employer

* Please list your monthly income

* Work Phone Number

Family Information

* Marital Status

Married Separated Divorced Single

* Spouse First Name

* Spouse Last Name

* Number in Family

* Has the Crisis Ministry provided assistance to you in the past?

* Please explain the circumstances that brought about this need.

Home Church Information

* Home Church

* Home Church Phone

* Home Church Pastor

Complex Information

* Name of Apartment Complex

* Complex Phone

* Complex Address

* Complex City

* Complex State

* Complex Zip Code

* Complex Contact Name

Monthly Expenses

* Rent

* Utilities

* Car Payment

* Food

* Child Care

* Phone

* Medical

* Gas/Oil

* Credit Cards

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