Applicant's Name
*
First Name
Last Name
Applicant's Date Of Birth
*
MM
DD
YYYY
Cell Phone Number
(###)
###
####
Applicant's Email Address
*
Marital Status
*
Single
Married
Divorced
Legally Separated
Are you Hispanic or Latino?
*
Regardless of your answer to the prior question, please indicate how you identify yourself. (Select one or more)
Do you live in Mecklenburg County?
*
Are you experiencing homelessness?
*
Please list your children's names, gender. age and date of birth
*
Do you have a teenage child that has had any engagement with Department of Juvenile Justice (DJJ)
Are you interested in furthering your Education?
*
Are you currently employed? (You MUST be employed for this program)
*
Do you need child care for a child not yet school age (under 5 years old)?
*
Do you need child care for a school-aged child outside of school hours?
*
What are your work hours?
Employer's Name
Address
Supervisor's Name
Supervisor's Phone Number
(###)
###
####
Do you currently have a bank account?
*
Name of Bank (if applicable)
Are you receiving?
*
Check all that apply
Are you receiving benefits from any other agency?
*
Please list any agency/agencies in which you are receiving benefits
Do you have any physical disabilities?
*
If yes to the above question, please explain
Do you or your child have any medical conditions?
*
If yes to the above question, please list conditions
Are you vaccinated for COVID-19?
*
You are required to be vaccinated to be a part of the program!
If no, will you get vaccinated at least 2 weeks before being housed with Gracious Hands?
*
Are you willing to test when showing symptoms of COVID-19 and isolate according to most recent guidelines if positive?
*
Referral Date
MM
DD
YYYY
Referral Agency/Facility
Referral Source Name
First Name
Last Name
Applicant's current living address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How long have you lived at your current address?
*
Where did you live before your temporary state of homelessness?
*
What is the reason for your current state of homelessness?
*
Do you have any court charges/cases pending?
*
Are you on Probation/Parole?
*
Do you have any of these charges?
Check all that apply
Please explain any of the above charges
Are you in need of just a bed for a night?
*
Are you looking to transition to sufficient housing?
*
Are you currently doing any drugs?
*
If yes, what is your choice of drug? Name all that apply.
Have you ever attended a rehab program before?
*
If yes, for how long?
For safety reasons, do you have a husband/boyfriend/partner looking for you?
*
If yes, please explain
Does the father of your child/children visit him/her on a regular basis?
*
Do you own a car?
*
If yes, please list the Make, Model, and Year
Proof of car insurance company
Date available for admission
MM
DD
YYYY
*
By submitting this application, you give Gracious Hands Transitional Housing permission to run a background check and check your credit score.
