Davidson CountyTornado Relief Assistance First Name Last Name Phone Number Email Address Street Address Street Address Continued City State Zip Code Provide the relationship between the applicant and each minor child living in the home and the child's age. Example, “Daughter, 13 years old.” Employment Status Full-timePart-timeTemporaryStudentUnemployedOther Name of Employer Type of Assistance Requested (Check each that applies) Rent/MortgageRent DepositUtilitiesFoodTransportation Where else are you seeking assistance? (Check each that applies) ChurchFriends and FamilyLadies of CharitySalvation ArmyOtherI am only asking Hope Station Ethnicity Black/African AmericanWhiteHispanicAsianMiddle EasternOtherPrefer Not to Answer Provide an overview of the assistance that you are requesting. Provide details about why the assistance is needed and the amount requested. What is your plan for next month? Please read and acknowledge statement below by typing your full name in the field that follows: Whether this application is accepted or rejected, I understand that paying my rent, mortgage payment, or utility bill is my responsibility. I understand that by filling out this application it does not guarantee my application will be approved. I certify that all information provided by me to Hope Station is true and correct to the best of my knowledge. I grant permission and authorize the following: 1) Hope Station may verify any and all information with creditors, landlords, or other social service agencies; 2) the information contained in my application may be shared with other social service agencies; 3) non-identifying information contained in my application may be shared with organizations, businesses, or individuals that fund or otherwise have interest in Hope Station’s assistance program. Release of Liability: To the fullest extent permitted by law, I hereby release and forever discharge and agree to indemnify and hold harmless Hope Station, Inc., its officers, agents, employees, and volunteers from and against any and all liabilities, claims, demands or causes of action of any kind on account of any loss, damage, illness or injury to person or property in any way arising out of or relating to my application for assistance and/or related activities, whether due to negligence, mistake, or other action or inaction of Hope Station, Inc. or any other person or entity acting on its behalf. Acknowledgement: By entering my name below and submitting this application, I acknowledge and agree to the terms above.