Skip to main content

Home About Programs Government Resources Apply Contact Donate

Apply for Services

Complete the application below to request support from Empower Her Village. Your information is secure and confidential. You can save your progress and return anytime.

1

Personal Info

2

Household

3

Govt. Assistance

4

Programs

5

Documents

6

Review & Submit

Personal Information

Tell us about yourself. All fields marked with * are required.

First Name *

Last Name *

Email Address *

Phone Number *

Street Address

City *

State

ZIP Code *

How did you hear about us?

Progress saved automatically

Household Information

Help us understand your family situation so we can match you with the right programs.

Are you the primary caregiver? *

Yes No

Number of Children in Household *

Number of Adults in Household

Ages of Children

Enter the number of children above to add their ages.

Currently Employed? *

Full-Time Part-Time Self-Employed Currently Seeking Employment Not Currently Employed

Estimated Annual Household Income *

Government Assistance History

Have you applied for any of the following government programs? If you were denied, uploading your denial letter helps us process your application faster.

Not sure what's available? Visit our Government Resources Hub →

TANF (Work First / Cash Assistance)

Haven't Applied Approved / Receiving Denied Unsure

Upload denial letter
PDF, JPG, or PNG — Max 10MB

SNAP (Food Stamps / EBT)

Haven't Applied Approved / Receiving Denied Unsure

Upload denial letter
PDF, JPG, or PNG — Max 10MB

WIC (Women, Infants & Children)

Haven't Applied Approved / Receiving Denied Unsure

Upload denial letter
PDF, JPG, or PNG — Max 10MB

NC Pre-K / Childcare Subsidy

Haven't Applied Approved / Receiving Denied Unsure

Upload denial letter
PDF, JPG, or PNG — Max 10MB

Medicaid / NC Health Choice

Haven't Applied Approved / Receiving Denied Unsure

Upload denial letter
PDF, JPG, or PNG — Max 10MB

Select Programs

Choose the programs you'd like to apply for. You can select multiple programs.

Short-Term Childcare Relief — Temporary childcare assistance Household Help & Cleaning — Domestic assistance services Mental Health & Wellness — Counseling and wellness resources Financial Literacy & Emergency Aid — Education and emergency support Community & Caregiver Network — Peer support and events

Tell us why you need these services

Preferred Frequency

Preferred Start Date

Supporting Documents

Upload documents to support your application. These help us verify eligibility and process your request faster.

Income Documentation

Pay stubs, W-2, tax return, or employer letter

Click or drag files here
PDF, JPG, PNG, or WebP — Max 10MB per file

ID Verification

Driver's license, state ID, or passport

Click or drag files here
PDF, JPG, PNG, or WebP — Max 10MB

Additional Documents (Optional)

Any other supporting documents you'd like to include

Click or drag files here
PDF, JPG, PNG, or WebP — Max 10MB per file

Review & Submit

Please review your application details below. Click "Edit" to make changes to any section.

I certify that the information provided is true and accurate to the best of my knowledge. I understand that Empower Her Village provides voucher-based support, not cash assistance. I authorize Empower Her Village to verify the information in this application.

Electronic Signature (Type Your Full Name) *

Date

Empower Her Village

For the moms who do it all but shouldn't have to. We bridge the gap between insufficient government assistance and the resources mothers need to thrive.

501(c)(3) Nonprofit • EIN: 93-3009209

Programs

All Programs
Government Resources
Apply for Services
Check Application Status

Get Involved

Donate
Partner With Us
About Us
Blog

Contact

Charlotte, NC
info@empowerhervillage.org
Contact Form

© 2026 Empower Her Village. All rights reserved.

Privacy Policy Terms of Service NC Disclosure