Booth Family Center Interest Form

Booth Family Center - Grass Valley, CA

Program Interest Form for Families
NOTICE

The Salvation Army Booth Family Center is a transitional living program for children and their parents. You must be someone that is raising one or more 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 may be done in consultation with the Nevada County Coordinated entry process.
Adult #1*

First NameLast Name
Date of Birth*

DayMonthYear
Gender*
Phone Number*
Adult #1 Employment/School Status*
Nationality (Optional)
Adult #2 (If Applicable)

First NameLast Name
Date of Birth (If Applicable)

DayMonthYear
Gender
Phone Number
Nationality (Optional)
Adult #2 Employment Status
Is Adult #1 and Adult #2 Legally Married?
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)*

CalFreshCashAidSSI or SSDIChild SupportWICN/AOther
Monthly household income amount*
Current or Most Recent Family Address*

Street Address

Street Address Line 2

CityState / Province

Explain Current Living Situation.
Email
example@example.com
How many people currently live in your household?*
Number of Dependents under 18?*
Names and ages of children under the age of 18.*
Are you or anyone in your household currently pregnant?*
Reason for needing program housing.*
Do you have any disabilities? (This does not determine your eligibility)

YesNo
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 AgreeI Disagree
I understand that if become part of the Booth Family Center program, I will be subject to a full background check.*

I AgreeI Disagree
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Booth Family Center - Grass Valley, CA

NOTICE