CRC Program Registration | Park Central Development

Community Resource Counseling Program Registration

Please complete the form to register for any and all of our residential services
Are you apart of the Rooted Program through Invest STL?*

YesNo
What staff member is filling out this application?*
Name*

First NameLast Name
Nickname
Date of Birth*

MonthDayYear
Age**
Gender**
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last 4# of Social**
Phone Number*
Please enter a valid phone number.
Email**
Neighborhood**
Referred Source-How did you hear about us?**
Race**
Other*
If other, please fill in below
Veteran Status**
Living Situation**
If other, please fill in below
Other
Marital Status**
Household Size**
How many Children(0-17years)?**
How many adults(18 - 59years)?**
How many Seniors(60+ years) ?**
With whom do you live? Please include children, parents, relatives, and/or friends.
Annual Household Income**
Source of Income**
Benefits Received**

No Benefits ReceivedAlimonyShort Term DisabilitySSI/SSDIWorkman’s Comp.Child SupportPensionSurvivor BenefitsUnemploymentDisability Ins. Inc.Rent SupplementTANFVeteran’s AssistanceFood Stamps (SNAP)Social SecurityOther
Other
Current Employer**
Write 'Not Employed' if not currently working
Status**
Previous Employer*
Status*
Are You Enrolled In School Now?
Name of School
Status
Highest Grade Completed*

Some high school, no degreeGraduated high schoolSome college creditTrade/tech/vocational trainingAssociates degreeBachelor’s degreeMaster’s degree/ Doctoral degree
Briefly describe the specifics of the problems with which you would like help (check all boxes that apply):*

Tax Relief - At Risk of ForeclosureTax Relief - Past Due (1+ years)Tax Relief - Recent Tax IncreaseRent/Mortgage AssistanceHousingChildcareTransportationUtilities assistanceEmployment opportunitiesFood accessHome repairsOther
Other*
Would you like to find and use your own contractors?*

YesNo
How much funding are you allotted for home repair?*
What repairs need to be completed?*
Are there any other services that you may need assistance with?

Mortgage AssistanceWater or Sewer AssistanceSenior Cleaning/Pest ControlHVAC Cleaning
Comments
Please comment if you were recently impacted by COVID-19. This includes, but is not limited to, job loss, decrease work hours, child(ren) unable to attend school, etc.) If you are applying for emergency utilities assistance due to overdue payment or an upcoming disconnection, please include the date of pending deadline. If you are applying for mortgage assistance, please state the number of months you are behind. If there is a pending eviction date, please state the date. If you are applying for home repair, please list what areas need repair.
Community Resource Counseling is a voluntary program aim to connect local residents to local resources to help them address their immediate needs. If you miss 3 scheduled appointments or are unavailable for contact after 3 tries, Park Central reserve the right to discontinue services.

Signature
Signature

Clear
Date

MonthDayYear
Should be Empty:

Community Resource Counseling Program Registration

Community Resource Counseling is a voluntary program aim to connect local residents to local resources to help them address their immediate needs. If you miss 3 scheduled appointments or are unavailable for contact after 3 tries, Park Central reserve the right to discontinue services.