Check In Form

1
Name* This field is required.
First Name
Last Name
2
Alias
3
Today's Date* This field is required.
Date
Year
Month
Day
4
Social Security Number* This field is required.
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.
Area Code
Phone Number
7
Email* This field is required.
example@example.com
8
Veteran* This field is required.
YESNO
9
Age* This field is required.
10
Date of Birth* This field is required.
Date
Year
Month
Day
11
Gender* This field is required.
Female
Male
Prefer Not To Respond
12
Primary Race* This field is required.
White
Hispanic
African American
Asian American
Prefer not to respond
13
Secondary Race
White
Hispanic
African American
Asian American
Prefer not to respond
14
Head Of Household* This field is required.
YESNO
15
If no, what is your relationship to the Head of Household?
Spouse
Partner
Family member
Other
16
Marital Status* This field is required.
Married
Single
Divorced
Widowed
Prefer Not To Respond
17
Number of people living in the household?* This field is required.
18
Emergency Contact #1 * This field is required.
First Name
Last Name
19
Emergency Contact #1 Phone Number* This field is required.
Area Code
Phone Number
20
Emergency Contact #2
First Name
Last Name
21
Emergency Contact #2 Phone Number
Area Code
Phone Number
22
Do you have an Arkansas photo ID?* This field is required.
YESNO
23
Current Living Situation* This field is required.
Rent
Own
Shelter
Homeless
Doubled Up
Transitional or Group Home
Other
24
Length of Current Living Situation* This field is required.
1-3 months
4-6 months
6-12 months
12 or more months
25
Prior Living Situation* This field is required.
Rent
Own
Shelter
Homeless
Doubled Up
Transitional or Group Home
Other
26
Length of Prior Living Situation* This field is required.
1-3 months
4-6 months
6-12 months
12 or more months
27
What town have you lived in the last three months?* This field is required.
28
What county have you lived in the past three months?* This field is required.
29
Do you live within Hot Springs city limits?* This field is required.
YESNO
30
Are you employed?* This field is required.
YESNO
31
Where are you employed?
32
If no, please explain.
33
List the source(s) and estimated amount(s) of your income.* This field is required.
$-Income
Wages or Salary
SNAP
WIC
Child Support
SSI
Disability
Other
Wages or Salary
SNAP
WIC
Child Support
SSI
Disability
Other
$-Income
$-Income
$-Income
$-Income
$-Income
$-Income
$-Income
$-Income
1 of 8
34
Can you provide proof of income?* This field is required.
YESNO
35
Monthly expenses* This field is required.
$
Housing
Utilities
Food
Other
Housing
Utilities
Food
Other
$
$
$
$
$
1 of 5
36
Have you experienced financial hardship due to Covid-19?* This field is required.
YESNO
37
Are you able to provide documentation of hardship?* This field is required.
YESNO
38
Do you have health insurance?* This field is required.
YESNO
39
Are you considered disabled?* This field is required.
Yes
No
Uncertain
40
What is your highest level of education?* This field is required.
Elementary School
Middle School
High School
Some college
College graduate
Graduate school
Technical school
Other
41
What is your source of transportation?* This field is required.
Personal vehicle
Public transportation
Carpool
Other
42
How did you find out about us?* This field is required.
Friend
Another agency, organization, or professional referral
Social Media or website
Other
43
Are you part of a faith community?* This field is required.
Yes
No
Prefer not to respond
44
Do you feel safe at home?* This field is required.
Yes
No
Prefer not to respond
45
Do you have a good support system?* This field is required.
Yes
No
Sometimes
Other
46
Please describe your need(s)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
47
Can you provide documentation regarding your need(s) such as bills or lease agreements?* This field is required.
YESNO
48
Is the documentation in your name?* This field is required.
Yes
No
Other
49
Have you requested assistance in the past?* This field is required.
YESNO
50
When?Month and Year
51
General Health* This field is required.
Excellent
Very good
Good
Fair
Poor
Other
52
Dental Health* This field is required.
Excellent
Very good
Good
Fair
Poor
Other
53
Mental Health* This field is required.
Excellent
Very good
Good
Fair
Poor
Other
54
Former Child Welfare/Foster?* This field is required.
YESNO
55
How many total years or months?
56
Unemployment* This field is required.
Yes
No
Uncertain
57
Mental Health Issues* This field is required.
Yes
No
Uncertain
58
Insufficient income and resources* This field is required.
Yes
No
Uncertain
59
Incarcerated Parents* This field is required.
Yes
No
Uncertain
60
Physical Disability* This field is required.
Yes
No
Uncertain
61
Alcohol or substance abuse* This field is required.
Yes
No
Uncertain
62
Trauma* This field is required.
Yes
No
Uncertain
Should be Empty:

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