Hope Program

Application for Assistance
Applicant Name *

First Name Last Name
Application Date

Month Day Year
Date

Physical Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email
example@example.com
SSN *
CDIB *
Phone Number *

Area Code Phone Number
All applicants must complete an interview with a caseworker before determination of assistance can be made. All assistance requires processing time. Applications are active for 10 business days. Determination of assistance is conducted on a case by case basis that includes documentation and assessment information.

If unable to be seen in-office, applicant may request a telephone interview. It is the client’s responsibility to call and schedule the telephone interview.

Documentation must be provided.
Briefly explain your crisis:
Unexpected, unplanned, or unforeseen incident: *
What type of assistance are you seeking today? (Please check all that apply) *

Food Utility Rent Funeral Transit Bus Pass Med ICU/Prescriptions
Complete your current sources of income (Click the + sign to add additional income): *
Are you a Veteran of the United States Military?

Yes No
Current housing situation *

Homeless Lease Rent Own Temp
Highest level of education? *

High School GED Some college Bachelors/Masters Did not graduate from high school
List ALL individuals currently living in your household, regardless of tribal affiliation or ethnicity. PLEASE LIST YOURSELF FIRST AND CLICK THE + SIGN TO ADD OTHER MEMBERS. *
I certify that information I have provided is true to the best of my knowledge. I understand this information will be usedto determine my eligibility for assistance with the HOPE Program and my signature allows tribal programs to share myinformation to determine eligibility. If you request a stop payment on your services after the check has been issued andmailed out, you will be suspended from the HOPE program for one year. *

Tribal Member Signature Clear
Today's Date

Month Day Year
Date
Code of Conduct Agreement

To ensure a cooperative, safe, and courteous environment, a Code of Conduct will be enforced by the Cheyenne and Arapaho HOPE Program. HOPE is focused on providing the client with caring and respectful service, making every
attempt to avoid any physical or emotional damage to either clients or staff. Please adhere to the following standards.

• Any inappropriate use of language is disrespectful or will not be tolerated.

• Threatening/intimidating remarks about the staff to other clients are also disrespectful and will not be
tolerated.

• Inappropriate behavior such as throwing objects, violent physical contact with others in the office, or
raising a voice in anger or contempt will not be tolerated.

• The staff will use respectful and professional behaviors with a client and anticipate the same behavior
from the client.

HOPE understands the difficulties of going through a crisis and will make every effort to make the application
process go quickly and smoothly. Please exhibit patience and understanding with the extensive application
process and be informed there are consequences for any inappropriate behavior
I, {applicantName}, have read and understand the Code of Conduct of the Cheyenne and Arapaho Tribes HOPE Program. By signing this agreement, I agree to adhere to the Code of Conduct and understand that if I breach the terms of the agreement, I will be placed on immediate suspension from the HOPE Program until my suspension is lifted.

Clear
Today's Date

Month Day Year
Date
Acknowledgement of Two Time Assistance Form ***REQUIRED for application to be processed***

Attach the signed and dated form below
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Cancel of
Should be Empty:

Application for Assistance

Briefly explain your crisis:

Acknowledgement of Two Time Assistance Form ***REQUIRED for application to be processed***

Acknowledgement of Two Time Assistance Form REQUIRED for application to be processed