Emaus Application

Release of Information
Name

First NameLast Name
Email
example@example.com
I, {name}, authorize the release of my personal information to Peregrinos De Emaus and/or associates. I understand that by signing this release of information, I am authorizing the disclosure of any and all information pertaining to my personal records.

I acknowledge that this release of information is voluntary and that I have the right to revoke it at any time by submitting a written request to Peregrinos De Emaus.

Please find my signature below indicating my authorization for the release of my personal information.
Signature

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Emaus Affidavit
Name

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
I, {name} agree to participate in the program from Los Angeles County called, "My First Place."

My First Place, is a program for the youth of Los Angeles County who are 18-26 years of age and are at risk of homelessness or housing insecurity.

I affirm that I or my family is experiencing any or all of the following:

-Homelessness

-Housing Insecurities

-At major risk of experiencing homelessness

-At major risk of experiencing housing insecurities

-Living in a car

-Living in a temporary space

-Will use the grant money for a primary place of living
Signature

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Date
Emaus Intake Form
Name*

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Last 4 of your SSN#*
Age Group:*
Are You Homeless:*
If yes, please write cross streets of where you are living.
Race:*
If Other (Please Specify):
Ethnicity:*
Gender:*
Veteran Status:*
Where you Referred?*
If Yes, Please Specify:
How did you hear about us?*
If other, please specify:
Please upload any lease or invoice that you have agreed to for funding.

Browse Files

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Please upload a picture of your photo ID.*

Browse Files

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Administrator Code:
For Administrators Only

Admin Section
ID Number:
Intake Notes:
Care Plan:
Basic Needs:

Needs Basic NeedsDeclined Basic Needs
Mental Health:

Needs Mental Health ReferralDeclined Mental Health Referral

Should be Empty:

Release of Information

Emaus Affidavit

Emaus Intake Form