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*
Format: (000) 000-0000.
Email *
example@example.com
Desired Move-In Date*

MonthDayYear
Select Date From Calendar
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
YesNo
If Yes, please provide details:
YesNo
If Yes, Please describe your current living situation:
Income
EmployedUnemployedDisabledOther
If Other, Please Specify
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
YesNo
If Yes, Please provide details:
YesNo
If Yes, Please provide details:
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