Mobile Request for Assistance Form

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Serving those impacted by incarceration

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Request For Assistance Form

Name: First, Middle, Last(Required)

DOC/Jail ID#(Required)

Are you Registered?(Required)

Yes

No

Birthdate(Required)

Month

Day

Year

Institution & Location(Required)

Counselor's Name(Required)

Conviction(Required)

Where: (City/County/State) were you convicted?(Required)

Release Date(Required)

Month

Day

Year

First Conviction(Required)

Yes

No

Number of Times(Required)

Number of Years(Required)

Was incarceration related to:(Required)

Alcohol abuse

Drugs abuse

Other

Have you been through treatment?(Required)

Yes

No

Where(Required)

When(Required)

Length of probation/parole(Required)

PO's Name/District(Required)

General Information

Your Hometown(Required)

Contact name of anyone who will help with your release(Required)

Contact phone # and address(Required)

Were you in the military?(Required)

Yes

No

Which Branch?(Required)

Education

Last grade completed(Required)

High School/GED

College

Trade school

Trade School Name / Trade(Required)

College/University Name / Major(Required)

Apprentice Program Type(Required)

Date completed(Required)

Month

Day

Year

Classes or Job Skills(Required)

Safe Serve

OSHA

Welding

Other

Work Experience

Work experience before incarceration(Required)

Work experience during incarceration(Required)

Family

Marital Status (pick all that apply)(Required)

Single

Married

Divorced

Never married

Cohabiting

Name of family contact (who will know where we can reach you)(Required)

Phone #(Required)

Relationship(Required)

# Boys & Ages

# Girls & Ages

Are children in foster care?(Required)

Yes

No

Where?(Required)

Guardian's name(Required)

Phone #(Required)

List your current request(s) from Kingsway. (We assume that if you do not list a need, you do not need anything.)(Required)

Please tell us anything you would like us to know about yourself: your interests, what you would like to accomplish in your current situation, and/or future goals.(Required)

Prayer concerns or requests(Required)

Your home plan address: Street Address, Apt #, State, City, Zip Code(Required)

Current phone # (If you have one)(Required)

Kingsway has my permission to verify this information and share it with other Christian people who might be able to help me.

Printed Name

Signature(Required)

Date(Required)

Month

Day

Year

Please Check Our Amazon Wish List For Items To Donate

Kingsway Prison and Family Outreach

Mailing Address:

PO Box 2335

Harrisonburg, VA 22801

Physical Location:

2217 S. Main St. (Dukes Plaza)

Harrisonburg VA. 22801

Office Hours:

Tuesday : 10:00 am - 2:00 pm

Wednesday: 10:00 am - 2:00 pm

Thursday: 10:00 am - 2:00 pm

Thursday: 2:00 pm - 5:00 pm (by appointment only)

Phone:

(540) 433-5658

Email:

info@kingswayoutreach.org

Webmaster:

Please report any broken links to kingswayoutreach.website@gmail.com

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Revised 8/7/2026

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