Request for assistance

Please complete this form so that we understand your need and how the church may be able to best help.  Requests for assistance are reviewed each week on Tuesday mornings.   Following this review, you will be contacted with information regarding next steps.

Personal Information






















Family Information

Employment & Income Information




Does anyone in your household receive the following?



























Monthly Expenses

Living Expenses

Transportation Expenses

Current Need

I authorize the release of information concerning me to Parkway Church or authorized volunteers of the Benevolence Ministry by any person or agency I have listed above that may be contacted on my behalf in order to determine how best to assist in this request. By my authorization below, I acknowledge that any agreements I have made to restrict access to personal information about me do not apply to this authorization. The authorization shall remain in force for 30 days following the date of my request submission, and a copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing at any time buy sending a written request for revocation to Parkway Church, 4802 John Stockbauer Drive, Victoria, TX 77904. I further understand that if I refuse to authorize the release of information, Parkway may not be able to process my application for assistance.



Submit