HH Application for Residency

Application

We are a Christ Centered 501c3 non-profit Maternity Support Home dedicated to provide women a place to call home while bringing them back from crisis to self-sufficency.
Are you currently Homeless?*

YesNo
Where did you sleep last night? *
Will you become homeless within the next 72 hours? *
Where do you sleep most frequently? *
Where are you from? *
Why are you in Cairo? *
Do you live in Grady County right now? *
Are you 18 years of age or older? *
What is your citizenship status? Citizen/Legal Resident/Undocumented *
Do you have your a valid Driver's License? *
If no license do you have a valid State issued photo id? *
Have you ever been arrested? *
Spent time in jail? *
What were the charges? *
Are you currently on probation or parole? *
Are you willing to undergo a drug test and background check? *
Are you currently pregnant? *
Do you have any children? If yes, how many boys? Ages? How many girls? Ages? *
Do you have any children that do not live with you? If yes, explain. *
In the last three years how many times have you been homeless and then housed again?*
Do you have any limitations keeping you from securing fulltime employment? If yes, describe.*
Are you experiencing abuse?*
If yes, what type of abuse? Physical, Emotional, or Mental *
Are you currently in a relationship with someone right now? If yes, explain.*
Step 1: PERSONAL INFORMATION
Full Name*

First NameMiddle NameLast Name
Phone Number*
Preferred Name/Nickname
Gender *

MaleFemale
DOB:*
E-mail*
Are you currently employed? If yes, who is your employer? Full-time or Part-time? *
Do you have a Highschool Diploma or GED?*
Highest level of education completed? *
Permenant/Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about this facility?*
Please list your reasons you would like to become a resident at The Handmaiden House *
Please share any immediate goals you may have. *
Please list any person(s) you would consider part of your support group. *
Please select a date/time you will be available for the phone interview.
Appointment
By clicking the submit button, I authorize The Handmaiden House to call me for a followup to assess my potential placement in their housing program. I also certify on my honor that the facts contained in this application are true and complete to the best of my knowledge and understand that, if any falsified statements on this application they shall be grounds for denial. I authorize investigation of all statements contained herein and release The Handmaiden House Inc. from all liability that may result from utilization of such information. This online application does not guarentee placement as this is only one part to the full assessment process. I understand that this is not a emergency homeless shelter meant for immediate occupancy but a 2-3 week process for admittance.
I have read and agree to the above statement*

I agree
Electronic Signature*

First NameLast Name
Application Completed*

MonthDayYear
Hour MinutesAM/PM Option
Signature

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