256-362-2114 info@phfc.org

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Secure Dwellings Program Initial Application

Home / Secure Dwellings Program Initial Application

Applicant's Name:*
First Last
Date of Referral:*
MM slash DD slash YYYY
Date of Birth:*
MM slash DD slash YYYY
Race:
Ethnicity:
Applicant's Best Contact Number:
Applicant's Secondary Contact Number (optional):
How soon is placement needed?
Referring Social Worker (if applicable):
First Last
Social Worker Phone Number
How long has applicant been homeless?
Where is applicant currently living?
How long has applicant lived there?
Any Minor Children (under 18 years old)?*
- Yes
- No
Legal Guardian:
- Yes
- No
Child's Name:
First Last
Child's Gender:
Child's Date of Birth:
MM slash DD slash YYYY
Child's Age:
Add another minor child?
- Yes
- No
Child's Name:
First Last
Child's Gender:
Child's Date of Birth:
MM slash DD slash YYYY
Child's Age:
Add another minor child?
- Yes
- No
Child's Name:
First Last
Child's Gender:
Child's Date of Birth:
MM slash DD slash YYYY
Child's Age:
Add another minor child?
- Yes
- No
Child's Name:
First Last
Child's Gender:
Child's Date of Birth:
MM slash DD slash YYYY
Child's Age:
Add another minor child?
- Yes
- No
Child's Name:
First Last
Child's Gender:
Child's Date of Birth:
MM slash DD slash YYYY
Child's Age:
Applicant currently pregnant?*
- Yes
- No
Has Applicant completed high school?*
- Yes
- No
Does Applicant have a GED?*
- Yes
- No
Interested in completing high school or GED?
- Yes
- No
Has Applicant attended/completed college?*
- Yes
- No
List school and degree for college education:
Interested in attending/completing college?
- Yes
- No
Are you receiving any educational financial aid?
- Yes
- No
Is Applicant Currently Working?*
- Yes
- No
Employer:
Hours per week:
Approximate Income:
Reason Unemployed:
Have you ever been a victim of domestic violence?*
- Yes
- No
When was your last experience?
Phone
This field is for validation purposes and should be left unchanged.

Address: 905 Ashland Hwy, Talladega, AL 35160

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Mail: P. O Drawer 577, Talladega, AL 35161

Phone: 256-362-2114

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Email: info@phfc.org

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The Presbyterian Home for Children is designated by the IRS as a tax-exempt 501(c)3 organization