#HELP Registration Form
The Help Project - Help Birmingham
We're here to #HELP
This form is a quick and conevenient information intake
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
Divorced
Married
Single
Widowed
Employment status
*
Disabled
Full Time
Part Time
Unemployed
Retired
If employed, how much is the monthly income? ($)
Please list the name of your employer(s)
*
How much is the monthly rent? ($)
How many are you in your household?
How many of them are children?
How many adults?
How many seniors?
Are you currently having issues paying utility bills on time? ( Power, Water, Gas, Internet, etc.)
Yes
No
Please list the details of your household below:
Signature
Clear
Date Signed
-
Month
-
Day
Year
Date
Housing Status
Are you able to pay your current rent/mortgage in full and on-time most months?
*
Yes
No
Are you in danger of eviction due to late or missing payments?
*
Yes
No
Are you currently enrolled in a rental assistance program?
*
Yes
No
If yes, what program?
Are you currently enrolled in the Section 8 program?
*
Yes
No
Is your current housing classified as "affordable housing"?
Yes
No
How long have you lived at your current location?
*
How many times have you moved in the last ten years?
*
Why did you move from your last residence?
*
COVID-19 QUESTIONS & SCREENING
Have you tested positive for COVID-19?
*
Yes
No
If so, When
Have you retested negative since then?
*
Yes
No
Never tested positive
If so, When
Are you currently experiencing any of the following symptoms?
New or worsening cough
New shortness of breath
Muscle or body aches
Nausea or vomiting
Difficulty breathing
Other
Has COVID-19 affected your income over the past 60 days?
*
Yes
No
If yes, please explain:
Homeless Status
Have you ever been homeless?
*
Yes
No
Are you currently homeless?
*
Yes
No
If so, when and for how long?
Needs Assessment
IN YOUR OPINIION, what are 3 things/problems that are threatening your current housing situation or putting you the position of needing help with your rent?
*
Do you own a car or have viable transportation?
*
Yes
No
Is the car in need of maintenance or repair?
*
Yes
No
In your own words, please briefly tell us what your situation is.
*
Submit
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