Genesis Joy House Admissions Application

Admissions Application

(Entry eligibility could take up to one week)
Identifying Information
Applicant Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at previous address?*
County of origin prior to entering program*
Phone Number*
Please enter a valid phone number.
Social Security Number*
Date of Birth*

MonthDayYear
Date
Place of Birth*
State ID or Driver's License?*

YesNo
License or ID Number
Expiration Date
Gender*
Race*
If Other or Multi-Racial, please specify
Ethnicity*
Applicant's Primary Language*
Secondary Language if applicable
Relationship Status*
If Other, please specify
Are you presently in a relationship?*

YesNo
Military Discharge Status
Are you a veteran?*

YesNo
Honorable Discharge?*

YesNo
Dishonorable Discharge?*

YesNo
DD214 received?*

YesNo
Discharge Code
If dishonorable discharge, state reason(s):
Emergency Contact
Emergency Contact Name*
Emergency Phone Number*
Emergency Complete Address (Street, City, State, ZIP)*
Prior Living Situation
Have you been homeless off and on or consistently in the past:*

2 Years3 Years
If so, why?
In the past thirty (30) days, what has been your living situation?*
If Other, please specify
Location Address (Street, City, State, ZIP)
Notes
Do you feel like harming yourself or others?*

YesNo
Notes
Criminal Background
Have you ever been convicted of a crime?*

YesNo
Are you currently on probation or parole?*

YesNo
If yes, what was/were your charge(s)
Reporting Status/Probation or Parole
County/State
Probation/Parole Officer’s name
Amount of fines, if applicable
PO’s phone number
Email address
Pending court date(s)
Signature

By signing my name, I agree that I have answered all questions truthfully. Sensitive medical information documentation must be received before being housed.
Date*

MonthDayYear
Date
Applicants Signature*

Clear
Should be Empty: