Greer Family Shelter Application

Family members applying to live at the shelter:

Adult 1

Adult 1 *

DOB *

SSN *

Phone *

Relationship *

Do you need to add another adult? *YesNo

Adult 2

Adult 2 *

DOB *

SSN *

Phone *

Relationship *

Children living with you at least 5 days/week

Child 1

Child 1 *

DOB *

Relationship *

Do you need to add another child? *YesNo

Child 2

Child 2 *

DOB *

Relationship *

Do you need to add another child? *YesNo

Child 3

Child 2 *

DOB *

Relationship *

Information about adults:

Adult 1

Last year of school completed *

Name of School *

Medical condition(s) *

Substance abuse history *

Mental health needs *

Legal issues *

Health Insurance *

Company *

Renews on *

Did you serve in the military? *Yesno

Military service branch *

Discharge date *

Honorable? *YesNo

Driver’s License # *

Outstanding fines *

Adult 2

Last year of school completed *

Name of School *

Medical condition(s) *

Substance abuse history *

Mental health needs *

Legal issues *

Health Insurance *

Company *

Renews on *

Did you serve in the military? *Yesno

Military service branch *

Discharge date *

Honorable? *YesNo

Driver’s License # *

Outstanding fines *

Emergency Contact

Emergency Contact *

Phone *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Relationship *

Employment

Adult 1

Curremt Employer *

Type of Work *

Date hired *

Supervisor's Name *

Supervisor's Phone *

List all employers within the last 2 years: *

Work skills: *

Adult 2

Curremt Employer *

Type of Work *

Date hired *

Supervisor's Name *

Supervisor's Phone *

List all employers within the last 2 years: *

Work skills: *

Income for all adults hoping to live at the shelter (include job, child support, disability, alimo ny, etc.):

Source *

Monthly amount *

Source

Monthly amount

Source

Monthly amount

Do you have a checking account? *YesNo

Do you have a savings account? *YesNo

What is the name of your bank? *

List every person or place you owe money (includefriends, loans, utilities, lawsuits, child support, creditcards, court fees, tickets, etc,):

Place

Amount

Place

Amount

Place

Amount

Place

Amount

Place

Amount

Place

Amount

Transportation:

Do you have access to a vehicle? *YesNo

Who owns it? *

If you own it, is it paid for? *YesNo

Who is the lien holder? *

License plate # *

Condition of vehicle *

Car insurance company *

Policy # *

Monthly insurance cost

Do you have a bicycle? *YesNo

Housing:

What is your present housing situation? *

Previous Addresses:

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Schools:

List all schools anyone presently attends. Include grade level for all children. *

Explain how you came to be in your current situation. *

Explain what you feel is your biggest barrier that results in your homeless s ituation. *

Explain what you can do to improve your life in the next 12 months. *

Additional Medical Information:

List all physicians, including location, telephone, and patient. *

List all prescriptions. (Name, Reason for use, Who takes it, and Frequency) *

List any allergies for each individual. *

A copy of the immunization record for each child will be required at the time of admission.

Signature(s):

Adult 1 *

Date *

Adult 2 *

Date *