Ruth's WARM House Application

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What is WARM?
Waynesboro Area Refuge Ministry (WARM) is a 501c3 organization that provides emergency and temporary housing to individuals and families who lack the resources to maintain stable housing. WARM provides winter/emergency shelter to homeless adults and temporary supportive housing to homeless women with children, and community outreach in Waynesboro and Augusta County, Virginia.

Our WARM House is a social model-transitional living program in Waynesboro, VA that provides temporary housing and support services to homeless women with children. The house, operated by the WARM Board of Directors and staff, solely exists to give women with children and experiencing homelessness a temporary house, time, support, and services that will enable them to transition from homelessness to independence. The WARM House’s structure offers accountability, drug testing, mentors, peer support, case management, training, and community referrals. For some cases, we do not offer any extensive services and refer all residents to the appropriate community services agencies to address their specific medical, financial, psychological, education, job-related, domestic violence, and/or substance abuse recovery-related needs.

The residential program can also have a 10% residency of single women without children if the occupancy, waiting list, and program elements allow so at the time of application. WARM can not serve individuals fleeing from domestic violence, stalking, or intimate partner violence at this site due to permit restrictions.

What is the cost of WARM’s services?
The primary purpose of the WARM House is to help homeless women with children transition into a more stable situation. Therefore, we provide our residence and services at no cost to the participants. WARM is financially supported by local churches and charitable donors that provide the means to cover the cost of the residents living quarters, program services, in-house activities, and basic needs. Each family is sponsored by an area congregation based on which room they occupy in the WARM House. Our goal is to allow each mother an opportunity to regain stability, with minimal financial obligations, while she is at the WARM House rebuilding her family’s future.

What are the eligibility requirements of WARM?
All participants must be eighteen years or older, homeless or without appropriate housing, have at least one child in their custody/care, must not have any unattended current warrants and/or capiases, must not be fleeing from a current domestic violence incidence, and must be willing to abide by WARM’s regulations and requirements.

For the safety of our staff and residents, we cannot give WARM House access to applicants that appear to be under the influence of alcohol or drugs at intake, in need of immediate medical and/or mental health treatment, or anyone believed to be a potential danger to themselves or others.

Also, WARM is unable to provide residency to sex offenders. Please contact our office if you would like further information on our eligibility requirements.

What is the process to participate with WARM?
Complete and submit an application (online or in-person by appointment only); if approved all participants meet individually with WARM Manager and/or Director to review the detailed rules and regulations of the program that include, but are not limited to, house curfews, house rules/policies, work/community service requirements, drug testing requirements, etc., sign a Participant/Program Contract, and begin residency if space is available or be placed on the WARM House Waiting List.

Residency is initially approved for 30 days and cannot exceed a total of 180 days. The program's primary goal is to help each family obtain stable housing upon exit.

***WARM. has an ongoing relationship with other local community agencies, the Department of Social Services, Child Protective Services, the local Department of Corrections, Parole/Probation, and Drug Court. Please be aware of our cooperation with these programs if your admission to our programs will be governed by one of these agencies or your residency at the WARM House will require regular reporting to others.**
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Please type your name to confirm that you have read this page in it's entirety.* This field is required.
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By whom were you referred?Case worker? Friend? Family Member? VHC Line?
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Name* This field is required.
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Birthdate* This field is required.
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SSN:* This field is required.
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Are you a veteran?* This field is required.
Yes
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Phone or Message Number:* This field is required.
Please enter the best number to contact you at to discuss your appliation.
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Previous Names, Maiden Name or Aliases Used:
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How long have you been where you slept last night?* This field is required.
One night or less
Two to six nights
One week, but less than a month
One month, but less than 90 days
90 days or more, but less than one year
One year or longer
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Age:
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Primary Race* This field is required.
Please choose one
Please choose one
American Indian or Alaska Native
Asian Indian
Black, African American
Chinese
Filipino
Guamanian or Chamorro
Japanese
Korean
Native Hawaiian
Samoan
Vietnamese
White
Other Asian
Other Pacific Islander
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Secondary Race* This field is required.
American Indian or Alaska Native
Asian Indian
Black, African American
Chinese
Filipino
Guamanian or Chamorro
Japanese
Korean
Native Hawaiian
Samoan
Vietnamese
White
Other Asian
Other Pacific Islander
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Ethnicity* This field is required.
Hispanic
Non-hispanic
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Height
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Weight:
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Please briefly share your homelessness (or risk of homelessness) situation. Is there any other important information that we should know about you (behavior, fears, issues, etc.?)* This field is required.
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Date this episode of homelessness started.* This field is required.
Date
Month
Day
Year
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Number of times you have been homeless in last 3 years.* This field is required.
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Do you have regularly received income?* This field is required.
Yes
No
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If yes, Income Amount:
If income changes, then please use an average of your income for below period that you choose.
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If yes, how often do your receive the income amount?
ie. Weekly, Bi-Weekly, Monthly
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If yes, Income Source(s):
Employment
Disability (ie. SSI, SS, SSDI)
Unemployment
Other
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If Applicable, Employer's Name:
Company Name
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If Applicable, Employer's Address:
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If Applicable, Employer's Telephone:
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If Applicable, Supervisor's Name:
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If Applicable, Position Held:
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If Applicable, Length of time at this job:Share number of years and/or months
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If you do not have a job, and are able to work, are you willing to gain employment?
Yes
No
N/A: I am unable to work.
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If yes, do you have any current job plans?
Yes
No
N/A: I am unable to work.
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If Applicable, please explain your current plans, or willingness, to obtain employment:
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Relationship Status:* This field is required.Please note that WARM has visitor policies that places restrictions and request processes for significant others visitation within the facility.
Married
Never Married
Separated
Divorced
Dating
Widow
Other
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Physician Name:
If none, please leave blank.
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Date of Last Visit:
Date
Month
Day
Year
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Are you currently pregnant?* This field is required.
Yes
No
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If yes, what is your due date?
Date
Month
Day
Year
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Do you have health insurance?* This field is required.
Yes
No
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If yes, who is your insurance provider or describe where you are in the process:
Ex. Virginia Premier, Aetna, etc.
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Has a physician diagnosed you with a disability?* This field is required.
Yes
No
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If yes, what disability have you been diagnosed with?* This field is required.
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Do you have allergies?* This field is required.
Yes
No
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If so, please describe allergy, severity, and if emergency response is needed during allergic reactions:
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Do you take medications regularly?* This field is required.
Yes
No
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If so, please list the medication(s) and frequency:
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Do you smoke?* This field is required.If yes, please note that we enforce a smoking policy with specified locations and hours.
Yes
No
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Are you a veteran?* This field is required.
Yes
No
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Do you receive any non-cash benefits?* This field is required.
I receive no non-cash benefits
WIC
SNAP/Food Stamps
TANF
Other
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Please list dollar amounts of non-cash benefitsInclude SNAP/Food Stamps/WIC/TANF
Huge
Large
Normal
Small
Ok
Ok
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Are you fleeing from a current domestic or intimate partner violence incident or do you fear for your safety in ANY way?* This field is required.Your response to this question does not necessarily impact program eligibility but allows us to determine the best resources and services to be offered
Yes
No
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If yes, please explain:
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Are you a registered sex offender or do you have pending charges for crimes related to inappropriate behavior with minors, sexual assault, lewd acts, etc.?* This field is required.
Yes
No
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If yes, please explain:
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Have you been/are you being treated or incarcerated for substance use, drug possession, or drug distribution?* This field is required.Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
Yes
No
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If yes, please explain:
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Are you currently on probation/parole or have any pending charges or court dates?* This field is required.Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
Yes
No
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If yes, please explain:
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Do you own (or currently drive a vehicle that you will have at WARM if accepted?* This field is required.Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
Yes
No
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Does the vehicle have current registration and insurance?* This field is required.Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
Yes
No
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If yes, vehicle make/model: blanks / color: /license plate: blank
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If applicable, Child 1:
First/Last Name / Gender Identity / Birthdate / Age School and/or Daycare Name
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If applicable, Child 2:
First/Last Name / Gender Identity / Birthdate / Age / School and/or Daycare Name
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If applicable, Child 2:
First/Last Name / Gender Identity / Birthdate / Age / School and/or Daycare Name
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If applicable, Child 3:
First/Last Name / Gender Identity / Birthdate / Age / School and/or Daycare Name
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If applicable, Child 4:
First/Last Name / Gender Identity / Birthdate / Age / School and/or Daycare Name
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Is your child/ren disabled?* This field is required.Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
Yes
No
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If yes, please indicate child's name and type of disability:
Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
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Does your child/ren have any allergies?* This field is required.Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
Yes
No
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If yes, please list child/ren and describe allergy, severity, and if emergency response is needed during allergic reactions (for each applicable child):
Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
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Does your child/ren take medication?* This field is required.Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
Yes
No
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If yes, please list the child's name and medications:
Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
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Has Child Protective Services, Foster Care Prevention, or any other child advocacy program had an open case on behalf of your child/ren?* This field is required.Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
Yes
No
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If yes, please list the child/ren's name, year(s) of active case, agency, and a brief description of the incidence(s)/case(s):
Your response to this question does not impact program eligibility but allows us to determine the resources and services offered that may assist you if you become a resident.
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Is there any other important information that we should know about your child/ren? (behaviors, fears, etc.)
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Please list any community resource providers, therapists, counselors, or others who are providing services to you and/or your child/ren. (ex. WIC, Salvation Army, Social Services, Court Services, Substance Use or Mental Health Providers, Churches, etc.)

*Name of Provider:   / Services Provided:       / Address:       / Phone:    Phone Number    / Caseworker or Rep Name:

*Name of Provider:   / Services Provided: School and/or Daycare Name / Address:
/ Phone: Phone Number / Caseworker or Rep. Name:

*Name of Provider:   / Services Provided: / Address:    / Phone: Phone Number / Caseworker or Rep. Name:

*Name of Provider:   / Services Provided: / Address:       / Phone: Phone Number / Caseworker or Rep. Name:

*Name of Provider:   / Services Provided: / Address: /Phone: Phone Number / Caseworker or Rep. Name:

*Name of Provider:   / Services Provided: / Address: /Phone: Phone Number / Caseworker or Rep. Name:
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What is your desired relationship with WARM?* This field is required.
Residential: I would like to be considered to live at Ruth's WARM House without charge of rent/utilities.
Referral: I need some help finding the right resources for my situation.
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Have you received services from any WARM program before? If so, please share which program and when* This field is required.
Please write yes or no and, if yes, program name and year
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Emergency Contact 1:
Name: Name * /Relationship: / Email: Email * /Phone: Phone Number *
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Emergency Contact 2:
Name: First Name /Relationship: / Email: Email /Phone: Phone Number
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Please read the Release of Information (ROI) prior to signing your application submission. Application signature will also populate the ROI signature field upon submission.
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Application Signature/ROI: I hereby acknowledge that the provided information is true and correct to the best of my knowledge. I understand that falsifying any information in this application can result in the denial of my participation in Ruth's WARM House. Furthermore, I understand that if accepted in Ruth's WARM House, my future continued eligibility can immediately be terminated if staff become aware of any false information provided at application. Additionally, my signature indicates my authorization for release of information regarding my application and, if accepted, residency at Ruth's WARM House in the manners stated in the Authorization of Release provided for viewing in this online application process.* This field is required.Your signature below is required for application submission.
Clear
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