Booth Family Center Interest Form

Booth Family Center Application

Located in Grass Valley, CA
NOTICE

The Salvation Army Booth Family Center is an EMERGENCY SHELTER transitional program for children and their parents residing within Nevada County, CA. You must be someone who is raising one or more minor children full-time to be eligible. This application does not guarantee housing. Completion of this form indicates your interest in the Booth Family Center, not a guaranteed place in the program. Family selection will be done in consultation with the Nevada County Coordinated Entry process.
This application must be filled out by the applicant(s) only. If you are a caseworker who is submitting a referral, please email jennifer.breazeale@usw.salvationarmy.org
Adult #1

First NameLast Name
Date of Birth

DayMonthYear
Gender
Phone Number
Format: (000) 000-0000.
Adult #1 Employment/School Status
Nationality (Optional)
Adult #2 (If Applicable)

First NameLast Name
Date of Birth (If Applicable)

DayMonthYear
Gender
Phone Number
Format: (000) 000-0000.
Nationality (Optional)
Adult #2 Employment Status
Is Adult #1 and Adult #2 Legally Married?
Both adults must be legally married and/or the biological parent of minor children in your care.
Are you or any of your household a CalWorks participant? If yes, please provide the details of the caseworker.
Are you or any of your household a CalWorks participant? If yes, please provide the details of the caseworker.
Do you receive any of the following? (Check all that apply)

Other
TOTAL monthly household income amount
Current or Most Recent Family Address

Street Address

Street Address Line 2

CityState / Province

Explain Current Living Situation. Do you currently reside at this address?
Email
example@example.com
How many people currently live in your household?
Number of Dependents under 18?
List the names and ages of dependents.
Applicants must have at least one child, under the age of 18, in their care full-time to qualify for the Booth Family Center.
Are you or anyone in your household currently pregnant?
Do you have any disabilities? (This does not determine your eligibility)
Please explain your need/desire to participate in the Booth Family Center program.
Please share any additional information that would be helpful as we review your initial application.
Which agency or individual referred you to The Booth Family Center?
The Salvation Army Booth Family Center is a zero-tolerance program. You and all members of your household must be 100% drug and alcohol-free, this includes THC. Please indicate your awareness of this rule and understanding that it is the standard held if admitted to our program.
I understand that if become part of the Booth Family Center program, I will be subject to a full background check.
I understand that if my family is accepted into the Booth Family Center Shelter Program, I will fully work towards obtaining and maintaining employment and housing.
Please Note:

By submitting this form, you acknowledge that you are not guaranteed a spot at the Booth Family Center. Your application will be reviewed in the order it was received, as well as in order of emergency circumstances. Your application will be reviewed in conjunction with Nevada County Social Services. If qualified, you will be contacted for a brief phone interview and possibly an in-person interview.
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Booth Family Center Application

NOTICE

Please Note: