JTHC APPLICATION
Today's Date
-
Month
-
Day
Year
01-01-2024
Your Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Your Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Email
example@example.com
Your Date of Birth
-
Month
-
Day
Year
Date
Your Marital Status
Please Select
Single
Married
Divorced
Widowed
Separated
Do you have any minor children?
Please Select
Yes
No
Where will your children be placed during your stay at Jackson Transitional Housing Center?
Please provide an Emergency Contact Name
Please enter Name
Please provide an Emergency Contact Phone Number
Please enter Phone Number
1. Why are you seeking JTHC for assistance?
2. Have you participated in using drugs or alcohol in the last 24 to 48 hours?
Please Select
Yes
No
If your answer to question 2 is No, when was the last time you used it?
If you haven't used any drugs, type "N/A"
3. Race & Ethnic Background
Please Select
Black or African American
Hispanic or Latin
White
Asian
Native American
Multiracial
Other
4. Are you a veteran?
Please Select
Yes
No
Are you taking any medication?
Please Select
Yes
No
If you are taking any medication, please describe.
5. Do you have any food allergies?
Please Select
Yes
No
If your answer to question 5 is Yes, please describe.
6. Are you receiving any government assistance?
Please Select
Yes
No
If your answer to question 6 is Yes, please select which assistance.
Please Select
1. Supplemental Security Income (SSI)
2. Medicaid
3. Housing Assistance
4. WIC
5. Affordable Care Act (ACT)
6. Other
7. How did you hear about us?
Please Select
Referral
Television
Social Media
Google
Third-Party
Other
8. What is your expectation from this program?
Submit
Should be Empty: