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Children, Families & Young Adults
Family Support Services
PHFC Thrift Store
Who We are
Leadership
History
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Overview
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Admissions
School Calendar
Get Involved
Planned Giving Options
Volunteer
Donate Today
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Secure Dwellings Program Initial Application
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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?
Email
This field is for validation purposes and should be left unchanged.