Apply Now Are you a registered Sex Offender or do you have an arson conviction? * Due to insurance issues we cannot accept anyone with a sex offense or an arson conviction. YES NO Applicant Name * First Name Last Name Social Security # * Address * Present (or last) address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Date of Birth * MM DD YYYY Have you previously stayed at a shelter? * YES NO Do you smoke? * YES NO Person to Notify in CASE OF EMERGENCY * First Name Last Name Relationship to application * Relative, friend, employer, etc. Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Church Church Name Pastor Address Location of Church Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### How long have you attended this church? Are you a U.S. Veteran? * YES NO Have you previously lived at Helping Hands? * Yes No If so, when? What happened? Where are you presently (be specific)? If in treatment, where? if in jail or prison, where? If in a shelter, which one? * Please summarize your criminal history Reference First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Occupation Participant Agreement Form * 1. I AGREE AND SHALL RESPECT ALL THE POLICIES OF HELPING HANDS OUTREACH CENTER 2. I AGREE THAT ANY INFRACTION OF THESE POLICIES WILL LEAD TO MY DISMISSAL WITHOUT NOTICE. 3. I AGREE THAT EVERY 7 DAYS A PERSONAL REVIEW WILL BE TAKEN TO DETERMINE MY LENGTH OF STAY. 4. I AGREE THAT I AM PHYSICALLY ABLE TO WORK AND THAT I AM EMPLOYABLE OR I AM PERMANENTLY DISABLED AND GETTING SSI OR SSDI AND AM ABLE TO PAY THE REQUIRED PROGRAM FEE. 5. I AGREE TO ATTEND THE REQUIRED CASE MANAGEMENT COUNSELING SESSIONS AS PART OF THE RESIDENCE PROGRAM FOR ACCOUNTABILITY; ANY DECEITFULNESS OR LYING ARE GROUNDS FOR DISMISSAL. 6. I AGREE TO PAY PROGRAM FEES EQUAL TO 30% OF MY GROSS INCOME Email * Full email address of applicant or other Date * Date Application Completed MM DD YYYY Is someone assisting you with this application * Yes No Name of the person assisting you (ie: Counselor, Director, etc) Name of Facility (ie: Treatment, Halfway House, Better Life, etc) Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Contact Thank you. Case Manager from Helping Hands Outreach will be in touch with you shortly!
