Muslim Community Services of San Diego, Inc. ~ Office phone: 619 696 9267 Mailing address: 4203 Genesee Ave, #174 ~ San Diego, CA 92117
APPLICATION FOR SERVICES
Provide accurate information. Failure to do so may result in disqualification for services.
Name: _____________________________ Phone:(_____)_______________ Cell: (____)______________ Address:_______________________________________________________ Email:___________________ Street # Apt# City Zip CASE WORKER:______________________
Gender: M or F
Languages Spoken:__________________________ Spouse’s name:________________________________
Children in home (names, age, gender):_______________________________________________________ Others living in home:_____________________________________________________________________ Employment:________________________
Other monthly expenses (list):_________________________________ Estimated monthly income:_____________
Cash aid (gov):_________
Is there food in the house?_______________________
Other assistance (list all orgs and amounts):____________________________________________________
Please briefly explain why you are requesting services: ___________________________________________
SIGNATURE:___________________________ OFFICE USE ONLY – NO WRITING IN THIS BOX PLEASE Notes:________________________________________________________________________________
Reviewed by: _____________________________________________________ Date:_______________ Requested action:_______________________________________________________________________
COMMENTS: 1. Circle all paperwork that you saw to confirm above information: LEASE/RENTAL AGREEMENT WELFARE PAPER
PHONE BILL DISABILITY
2. Notes about what assistance this family has received/is receiving from other sources:
3. Transportation: Does this family have a car? Do they live close to a bus stop and are they able to take the bus? Do they need a bus pass? DO THEY NEED A RIDE TO JUMUAH? How many adult males in the household? 4. Does the family have a mushaf? Translation of Qurâ€™an in their language?
5. Who at this address is working? Who is looking for work? What are their qualifications/skills? Are the sisters able to do homecare?
6. Any notes about how to find apartment/house:
7. Other comments: