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HOUSING APPLICATION
Housing Application Eng
Tillman Ross
2019-04-24T14:23:45-04:00
"
*
" indicates required fields
Housing Screening
Name
*
First
Middle
Last
Email
*
Phone
*
Birth Date
*
Month
Day
Year
Gender
*
Male
Female
Are you pregnant?
*
Yes
No
When are you due?
*
Month
Day
Year
Are you receiving prenatal care?
*
Yes
No
What languages do you speak?
*
English
Spanish
French
Other
Race
*
African American
Asian
Caucasian/White
Hispanic
Native American
Other
Marital Status
*
Single
Married (check only if your spouse needs housing too)
Divorced/Separated
Other
Are you currently homeless?
*
Yes
No
Please select the city you reside in.
*
Concord
Harrisburg
Kannapolis
Midland
Mount Pleasant
Other
Hidden
Last known address
*
Hidden
City
*
Hidden
County
*
Hidden
State
*
Hidden
Zip Code
*
Briefly explain your current living situation.
*
Do you have children?
*
Yes
No
If your children are school-aged, what school district are they in?
How many people in your household need housing EXCLUDING YOU?
*
Please enter a number less than or equal to
10
.
Have you previously been in a shelter or housing program?
*
Yes
No
Shelter name and contact number
*
Are you currently employed?
*
Yes
No
Do you own a car?
*
Yes
No
Do you have a valid driver's license?
*
Yes
No
Do you or any of your family members have special health needs?
*
Yes
No
Please explain the special health needs.
Do you suffer from mental health issues?
*
Yes
No
Have you been told by a doctor that you have any of the following mental health concerns? Please check all that apply.
Depression
PTSD
Bi-Polar
Anxiety
Schizophrenia
Eating Disorder
Personality Disorder
Other
Please explain the mental health issues.
Have you ever been treated for alcohol or substance abuse?
*
Yes
No
Please explain the alcohol or substance abuse.
Are you currently fleeing domestic violence?
*
Yes
No
Has your family experienced domestic violence in the past?
*
Yes
No
Have you ever been convicted?
*
Yes
No
Do you have pets?
*
Yes
No
Is this a service animal?
*
Yes
No
Are there any past or present medical concerns, which would prevent your ability to sustain employment?
*
Yes
No
Do you have childcare?
*
Yes
No
Household Member #1 Name
*
Household Member #1 Birthdate
*
Month
Day
Year
Household Member #1 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #1 Gender
*
Male
Female
Household Member #2 Name
*
Household Member #2 Birthdate
*
Month
Day
Year
Household Member #2 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #2 Gender
*
Male
Female
Household Member #3 Name
*
Household Member #3 Birthdate
*
Month
Day
Year
Household Member #3 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #3 Gender
*
Male
Female
Household Member #4 Name
*
Household Member #4 Birthdate
*
Month
Day
Year
Household Member #4 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #4 Gender
*
Male
Female
Household Member #5 Name
*
Household Member #5 Birthdate
*
Month
Day
Year
Household Member #5 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #5 Gender
*
Male
Female
Household Member #6 Name
*
Household Member #6 Birthdate
*
Month
Day
Year
Household Member #6 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #6 Gender
*
Male
Female
Household Member #7 Name
*
Household Member #7 Birthdate
*
Month
Day
Year
Household Member #7 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #7 Gender
*
Male
Female
Household Member #8 Name
*
Household Member #8 Birthdate
*
Month
Day
Year
Household Member #8 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #8 Gender
*
Male
Female
Household Member #9 Name
*
Household Member #9 Birthdate
*
Month
Day
Year
Household Member #9 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #9 Gender
*
Male
Female
Household Member #10 Name
*
Household Member #10 Birthdate
*
Month
Day
Year
Household Member #10 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #10 Gender
*
Male
Female
If we are not able to provide you with services at this time, do we have your permission to share your information with other agencies that could possibly assist you?
*
Yes
No
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.
61993
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