Housing Program Registration Form

Participant Information

Please fill in the form below
Date*

MonthDayYear
Today's Date
Full Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Phone Number*
Email *
example@example.com
Desired Move-In Date*

MonthDayYear
Select Date From Calendar
Where would you like to live in Georgia (Select ALL that Apply)?*

AtlantaDecaturStone MountainEast PointUnion CityLawrencevilleMaconOther
If Other, please list the city that you would like to live.
Background
Military Branch of Service*
Enlistment Date

MonthDayYear
Discharge Date

MonthDayYear
Military Discharge
Have you ever been convicted of a crime?*

YesNo
If Yes, please provide details:
Have you experienced homelessness in the past 12 months?*

YesNo
If Yes, Please describe your current living situation:
Income
Employment Status*

EmployedUnemployedDisabledOther
If Other, Please Specify
Source of Income*

EmployedDisability BenefitsSocial Security BenefitsVeteran's BenefitsOther
If Other, Please Specify
Can you pay at least $800 per month for housing?*
If not, please enter the amount that you can pay each month for housing?
Enter Dollar Value Only
Health Information
Do you have any physical health conditions or disabilities?*

YesNo
If Yes, Please provide details:
Do you have any mental health conditions or concerns?*

YesNo
If Yes, Please provide details:
Taking any medications, currently?*

YesNo
Please list them here
Housing Goals
Is there anything else you would like us to know about about your situation or any specific needs that you have?
Describe your goals while participating in the transitional housing program
Should be Empty:

Participant Information

Background

Income

Health Information

Housing Goals