Shelter Application - Friendship Mission

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Today's Date

Name *

First

Middle

Last

Do you use any other names? If so, please list here.

Telephone Number *

Social Security Number *

Date of Birth *

Gender *

Ethnicity

Race ( select all the apply)

Layout have? all

Were you ever active-duty military? *

Yes
No
Client Doesn’t Know
Client Refused

Do you have a disabling condition? *

If you take any medication, please list:

Disability Type? (select all that apply)

Do you expect your disability to be long term?

Are you receiving medical treatment for your disability?

Do you have a Continuum ID card? *

Enter Continuum ID Number

Can you pass a drug test?

If you cannot pass a drug test, for what will you fail?

What type of Health Insurance do you have?

Have you been continuously homeless for one year? *

What is your relation to the Head of Household?

Where did you stay last night?

How long have you been staying where you were last night?

Number of times you have been homeless in the past three years?

1
2
3
4 or more

If 4 or more, what is the total number of months you have been homeless in the past three years?

What is the total number of months that you have continuously been homeless immediately prior to coming to this shelter?

Are you a domestic violence victim/survivor? *

When did it occur?

Past 3 months
3-6 Months Ago
6-12 Months Ago
More than a Year

Are you currently fleeing domestic violence?

Are you currently working? *

When is the last time you had a job?

What type of income do you receive? (Select all that apply AND enter amount in the box)

Amount of income you receive

What type of Non-Cash Benefits do you receive? (Select all that apply AND enter amount in the box)

Amount of non-cash benefits you receive

Are you bringing children into shelter with you? *

Child

Childs Name

Social Security Number

Date Of Birth

Gender

Ethnicity

Race ( select all the apply)

Relationship to Head of Household

Are they disabled?

Health Insurance?

Health Insurance Carrier