EveryONE Matters Ministries Program Application

EveryONE Matters Ministries Program Application
EMM provides transitional housing in the form of trailers & 5th wheels to families who are homeless. Maximum of 5 people per trailer depending on size of the trailer. Every participant in our program is assigned a mentor that assists with money management, resources, and developing a plan of action for clients to graduate into permanent housing.

If you are in need, please complete the below application, and our Program Manager will reach out to you for further intake.
Name*

First Name Last Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How do you prefer we contact you?*

PhoneTextEmail
Birthdate*

MonthDay Year
Date
Do you have children?*

YesNoYes, but they do not live with meOther
Children(s) Name & Age
Please list any other occupants including your relationship to them (spouse, other adults):
Do you have a pet?*

YesNo
If yes, what kind? Is it a service animal?
*Pets are subject to approval
What is your current living situation?*

Living in a shelterLiving in my carHotelFriends/FamilyOther
How long have you been experiencing homelessness?
What do you believe led to your homelessness situation?
Loss of job, domestic violence, separation/divorce, medical emergency, drug abuse, etc.
What city are you currently staying?*
What was your last stable housing situation?
Check all forms of income that apply to your household:*

DisabilitySocial SecurityUnemploymentPart Time JobFull Time JobCash AidFood StampsChild SupportSpousal SupportOther
What is your total NET income (after taxes) Please include all household incomes?*
Employer (if applicable)
Length of employment (if applicable)

Please list your approximate monthly expenses:*

	Total Monthly Cost	Total Debt on account (if applicable)
Car payment
Gas
Groceries
Credit Card payment
Hygiene Items
Alcohol, Cig, other habits
Other expenses (please label what expense is for)

Do you have any evictions on your record?*
Credit Score (recommend Credit Karma for free if you don't know it)*
Have you ever been accused or convicted of a crime?*

YesNo
If yes, please explain the situation below:
Are you willing to submit a background check?*

YesNo
Please select any of the following you have used in the last 30 days:*

MarijuanaCocaineMethOpioids (prescription pain meds)HeroineEcstacy/MollyAlcoholNoneOther
How often do you use the above?*
Please list any other alcohol or tobacco use:
Cigarettes, alcohol, tobacco, e-cig
What is your support system?*
Ie. Local family/friends, church, job, none
Have you experienced domestic violence/intimate partner violence?*

YesNo
If so, when did it occur?
What are you short term goals in the next few months?*
Ie. New job, healthy relationships, stable housing, more income, better health, financial stability, no debt
What are your long term goals in the next year?*
Ie. New job, healthy relationships, stable housing, more income, better health
Why do you believe this program would benefit you/your family?*
Are you willing to follow the requirements of this program if enrolled? (Meeting weekly with Case Manager/Mentor, Paying Rent on-time monthly, weekly budget worksheets, possible life skills classes/counseling)*

YesNoOther
Should be Empty: