Rogue Retreat Application

1
Full Name* This field is required.Head of Household
First Name
Last Name
2
Is Translation Assistance Needed For Head Of Household?* This field is required.
Yes
No
Don't Know
Prefer Not To Answer
3
Check Language* This field is required.
Arabic
Spanish
Afrikaans
American Sign Language
Black American Sign Language
Chinese
French
Tlingit
Ukrainian
Other
4
Email Address
example@example.com
5
Contact Number
6
Is It Ok To Text You
YESNO
7
Mailing AddressIf you do not currently have any address where you can receive mail click next.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Select The Program(s) You Are Applying For* This field is required.Kelly Shelter requires DAILY check in to remain on the waiting list. All others require check in once every 30 days.
Kelly Shelter
RR Crossings (campground)
Hope Village (requires 30 days clean)
Women and Children Haven
Men and Children Haven
Restart Retreat 1 Bedroom
Restart Retreat 2 Bedroom
Housing Retreat 1 Bedroom
Housing Retreat 2 Bedroom
9
Social Security Number for Head of Household* This field is required.
10
Are you a US Military Veteran* This field is required.Head of Household
YESNO
11
Date of Birth* This field is required.Head of Household
Date
Month
Day
Year
12
What Is Your Gender? (Head of Household)* This field is required.State of Oregon requires that we ask this question
Please Select
Please Select
Woman
Man
Culturally Specific (eg: Two Spirit)
Non-Binary
Transgender
Questioning
Different Identity than those listed
Do Not Know
Prefer Not To Answer
13
Sexual Orientation (Head of Household)* This field is required.State of Oregon requires that we ask this question
Please Select
Please Select
Heterosexual
Gay
Lesbian
Bisexual
Questioning/Unsure
Other
Do Not Know
Prefer Not To Answer
14
Check All That Apply for Head of Household* This field is required.State of Oregon requires we ask this question
American Indian/Alaskan Native/Indigenous
Asian or Asian American
Black, African American or African
Hispanic/Latin
Middle Eastern or North African
Native Hawaiian/Pacific Islander
White
Do Not Know
Prefer Not To Answer
15
Household Type* This field is required.If you are not a single individual and ended up here click "Previous" and enter information for other members of your household.
Single Individual
Couple No Children
Female Single Parent
Male Single Parent
Two Parent Family
Grandparent and Child
Foster Parent(s)
Non-Custodial Caregiver
16
Where did you sleep last night?* This field is required.Please be specific, you do not need to disclose your location. Examples: Emergency Shelter, Hospital, Jail, Street, Car, Camp, with Family/Friends, etc
Huge
Large
Normal
Small
Ok
Ok
17
Length Of Stay In The Place You Stayed Last Night* This field is required.(How long IN A ROW this homeless episode?)
One day or less
2 days to one week
More than a week, less than a month
1-3 months
More than 3 months, less than a year
One year or longer
Do not know
Prefer not to answer
18
Approximate Date THIS PERIOD of Homelessness Started?* This field is required.Head of Household
Date
Month
Day
Year
19
How many times have you stayed on the street, in an emergency shelter or shelter in the past 3 years including today?* This field is required.Head of Household
1 Time
2 Times
3 Times
4 or More Times
20
Total Number Of Months Experiencing Homelessness In The Last 3 Years?* This field is required.Head of Household
21
Have you ever received services from Rogue Retreat?* This field is required.
YESNO
22
Who in your household has received service? - Include what type of services.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
23
Do you have a service animal or pet?* This field is required.
YESNO
24
What kind of animal and how many?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
25
Do You Have Health Insurance?* This field is required.Head of Household
Medicaid/OHP
Medicare
State Children HI
Veteran (VHA)
From Employer
COBRA
Private Pay
Indian Services
No
Do Not Know
Prefer Not To Answer
Other
26
Do You Have A Disabling Condition? Check All That Apply* This field is required.United States Department of Housing and Urban Development requires we ask this question
Alcohol Use Disorder
Drug Use Disorder
Developmental
HIV/AIDS
Mental Health Disorder
Physical
Chronic Health Condition
None
27
If Applying For Kelly Shelter, Can You Use A Top Bunk?Head of Household
YESNO
28
If Applying For Other Projects Does ANYONE In Your Household Require Special Features? If So, What Are They?* This field is required.
None
Grab Rails
No Stairs
Hearing Impaired Smoke Detectors
Other
29
How Long Have You Resided In Jackson County?* This field is required.Head of Household
30
Do You Receive Food Stamps? (SNAP EBT)* This field is required.Head of Household
YESNO
31
Enter Monthly Amount Received (SNAP EBT)* This field is required.
32
Do You Receive WIC?* This field is required.Head of Household
YESNO
33
Enter Monthly Amount Received WIC* This field is required.
34
Do You Receive Any Reliable Income Each Month?* This field is required.Head of Household
YESNO
35
Enter Amount Of Reliable Income* This field is required.
36
Do You Need To Add A 2nd Individual?
YESNO
37
Individual #2 Full Name* This field is required.
First Name
Last Name
38
Individual #2 Social Security Number* This field is required.
39
Individual #2 Are you a US Military Veteran?* This field is required.
YESNO
40
Individual #2 Date of Birth* This field is required.
Date
Month
Day
Year
41
Individual #2 What Is Your Gender?* This field is required.State of Oregon requires that we ask this question
Please Select
Please Select
Woman
Man
Culturally Specific (eg: Two Spirit)
Non-Binary
Transgender
Questioning
Different Identity than those listed
Do Not Know
Prefer Not To Answer
42
Individual #2 Sexual Orientation* This field is required.State of Oregon requires that we ask this question
Please Select
Please Select
Heterosexual
Gay
Lesbian
Bisexual
Questioning/Unsure
Other
Do Not Know
Prefer Not To Answer
43
Individual #2 Check All That Apply* This field is required.State of Oregon requires we ask this question
American Indian/Alaskan Native/Indigenous
Asian or Asian American
Black, African American or African
Hispanic/Latin
Middle Eastern or North African
Native Hawaiian/Pacific Islander
White
Do Not Know
Prefer Not To Answer
44
Individual #2 What Is Your Relationship To Head Of Household?* This field is required.
Child
Spouse/Partner
Non-Relation
Other
45
Individual #2 Approximate Date THIS PERIOD of Homelessness Started?* This field is required.
Date
Month
Day
Year
46
Individual #2 How many times have you stayed on the street, in an emergency shelter or shelter in the past 3 years including today?* This field is required.
1 Time
2 Times
3 Times
4 or More Times
47
Individual #2 Total Number Of Months Experiencing Homelessness In The Last 3 Years?* This field is required.
48
Individual #2 Do You Have Health Insurance?* This field is required.
Medicaid/OHP
Medicare
State Children HI
Veteran (VHA)
From Employer
COBRA
Private Pay
Indian Services
No
Do Not Know
Prefer Not To Answer
49
Individual #2 Do You Have A Disabling Condition? Check All That Apply* This field is required.United States Department of Housing and Urban Development requires we ask this question
Alcohol Use Disorder
Drug Use Disorder
Developmental
HIV/AIDS
Mental Health Disorder
Physical
Chronic Health Condition
None
50
Individual #2 If Applying For Kelly Shelter, Can You Use A Top Bunk?
YESNO
51
Individual #2 How Long Have You Resided In Jackson County?* This field is required.
52
Individual #2 Do You Receive Food Stamps? (SNAP EBT)* This field is required.
YESNO
53
Individual #2 Enter Monthly Amount Received (SNAP EBT)* This field is required.
54
Individual #2 Do You Receive WIC?* This field is required.
YESNO
55
Individual #2 Enter Monthly Amount Received for WIC* This field is required.
56
Individual #2 Do You Receive Any Reliable Income Each Month?* This field is required.
YESNO
57
Individual #2 Enter Monthly Amount Received for Income* This field is required.
58
Do You Need To Add A 3rd Individual?
YESNO
59
Individual #3 Full Name* This field is required.Head of Household
First Name
Last Name
60
Individual #3 Social Security Number* This field is required.
61
Individual #3 Are you a US Military Veteran?* This field is required.
YESNO
62
Individual #3 Date of Birth* This field is required.
Date
Month
Day
Year
63
Individual #3 What Is Your Gender?* This field is required.State of Oregon requires that we ask this question
Please Select
Please Select
Woman
Man
Culturally Specific (eg: Two Spirit)
Non-Binary
Transgender
Questioning
Different Identity than those listed
Do Not Know
Prefer Not To Answer
64
Individual #3 Sexual Orientation* This field is required.State of Oregon requires that we ask this question
Please Select
Please Select
Heterosexual
Gay
Lesbian
Bisexual
Questioning/Unsure
Other
Do Not Know
Prefer Not To Answer
65
Individual #3 Check All That Apply* This field is required.State of Oregon requires we ask this question
American Indian/Alaskan Native/Indigenous
Asian or Asian American
Black, African American or African
Hispanic/Latin
Middle Eastern or North African
Native Hawaiian/Pacific Islander
White
Do Not Know
Prefer Not To Answer
66
Individual #3 What Is Your Relationship To Head Of Household?* This field is required.
Child
Spouse/Partner
Non-Relation
Other
67
Individual #3 Approximate Date THIS PERIOD of Homelessness Started?* This field is required.
Date
Month
Day
Year
68
Individual #3 How many times have you stayed on the street, in an emergency shelter or shelter in the past 3 years including today?* This field is required.
1 Time
2 Times
3 Times
4 or More Times
69
Individual #3 Total Number Of Months Experiencing Homelessness In The Last 3 Years?* This field is required.
70
Individual #3 Do You Have Health Insurance?* This field is required.
Medicaid/OHP
Medicare
State Children HI
Veteran (VHA)
From Employer
COBRA
Private Pay
Indian Services
No
Do Not Know
Prefer Not To Answer
71
Individual #3 Do You Have A Disabling Condition? Check All That Apply* This field is required.United States Department of Housing and Urban Development requires we ask this question
Alcohol Use Disorder
Drug Use Disorder
Developmental
HIV/AIDS
Mental Health Disorder
Physical
Chronic Health Condition
None
72
Individual #3 If Applying For Kelly Shelter, Can You Use A Top Bunk?
YESNO
73
Individual #3 How Long Have You Resided In Jackson County?* This field is required.
74
Individual #3 Do You Receive Food Stamps? (SNAP EBT)* This field is required.
YESNO
75
Individual #3 Enter Monthly Amount Received (SNAP EBT)* This field is required.
76
Individual #3 Do You Receive WIC?* This field is required.
YESNO
77
Individual #3 Enter Monthly Amount Received for WIC* This field is required.
78
Individual #3 Do You Receive Any Reliable Income Each Month?* This field is required.
YESNO
79
Individual #3 Enter Monthly Amount Received for Income* This field is required.
80
Do You Need To Add A 4th Individual?
YESNO
81
Individual #4 Full Name* This field is required.
First Name
Last Name
82
Individual #4 Social Security Number* This field is required.
83
Individual #4 Are you a US Military Veteran?* This field is required.
YESNO
84
Individual #4 Date of Birth* This field is required.
Date
Month
Day
Year
85
Individual #4 What Is Your Gender?* This field is required.State of Oregon requires that we ask this question
Please Select
Please Select
Woman
Man
Culturally Specific (eg: Two Spirit)
Non-Binary
Transgender
Questioning
Different Identity than those listed
Do Not Know
Prefer Not To Answer
86
Individual #4 Sexual Orientation* This field is required.State of Oregon requires that we ask this question
Please Select
Please Select
Heterosexual
Gay
Lesbian
Bisexual
Questioning/Unsure
Other
Do Not Know
Prefer Not To Answer
87
Individual #4 Check All That Apply* This field is required.State of Oregon requires we ask this question
American Indian/Alaskan Native/Indigenous
Asian or Asian American
Black, African American or African
Hispanic/Latin
Middle Eastern or North African
Native Hawaiian/Pacific Islander
White
Do Not Know
Prefer Not To Answer
88
Individual #4 What Is Your Relationship To Head Of Household?* This field is required.
Child
Spouse/Partner
Non-Relation
Other
89
Individual #4 Approximate Date THIS PERIOD of Homelessness Started?* This field is required.
Date
Month
Day
Year
90
Individual #4 How many times have you stayed on the street, in an emergency shelter or shelter in the past 3 years including today?* This field is required.
1 Time
2 Times
3 Times
4 or More Times
91
Individual #4 Total Number Of Months Experiencing Homelessness In The Last 3 Years?* This field is required.
92
Individual #4 Do You Have Health Insurance?* This field is required.
Medicaid/OHP
Medicare
State Children HI
Veteran (VHA)
From Employer
COBRA
Private Pay
Indian Services
No
Do Not Know
Prefer Not To Answer
93
Individual #4 Do You Have A Disabling Condition? Check All That Apply* This field is required.United States Department of Housing and Urban Development requires we ask this question
Alcohol Use Disorder
Drug Use Disorder
Developmental
HIV/AIDS
Mental Health Disorder
Physical
Chronic Health Condition
None
94
Individual #4 If Applying For Kelly Shelter, Can You Use A Top Bunk?
YESNO
95
Individual #4 How Long Have You Resided In Jackson County?* This field is required.
96
Individual #4 Do You Receive Food Stamps? (SNAP EBT)* This field is required.
YESNO
97
Individual #4 Enter Monthly Amount Received (SNAP EBT)* This field is required.
98
Individual #4 Do You Receive WIC?* This field is required.
YESNO
99
Individual #4 Enter Monthly Amount Received For WIC* This field is required.
100
Individual #4 Do You Receive Any Reliable Income Each Month?* This field is required.
YESNO
101
Individual #4 Enter Monthly Income Amount Received* This field is required.
102
Do You Need To Add A 5th Individual?
YESNO
103
Individual #5 Full Name* This field is required.
First Name
Last Name
104
Individual #5 Social Security Number* This field is required.
105
Individual #5 Are you a US Military Veteran?* This field is required.
YESNO
106
Individual #5 Date of Birth* This field is required.
Date
Month
Day
Year
107
Individual #5 What Is Your Gender?* This field is required.State of Oregon requires that we ask this question
Please Select
Please Select
Woman
Man
Culturally Specific (eg: Two Spirit)
Non-Binary
Transgender
Questioning
Different Identity than those listed
Do Not Know
Prefer Not To Answer
108
Individual #5 Sexual Orientation* This field is required.State of Oregon requires that we ask this question
Please Select
Please Select
Heterosexual
Gay
Lesbian
Bisexual
Questioning/Unsure
Other
Do Not Know
Prefer Not To Answer
109
Individual #5 Check All That Apply* This field is required.State of Oregon requires we ask this question
American Indian/Alaskan Native/Indigenous
Asian or Asian American
Black, African American or African
Hispanic/Latin
Middle Eastern or North African
Native Hawaiian/Pacific Islander
White
Do Not Know
Prefer Not To Answer
110
Individual #5 What Is Your Relationship To Head Of Household?* This field is required.
Child
Spouse/Partner
Non-Relation
Other
111
Individual #5 Approximate Date THIS PERIOD of Homelessness Started?* This field is required.
Date
Month
Day
Year
112
Individual #5 How many times have you stayed on the street, in an emergency shelter or shelter in the past 3 years including today?* This field is required.
1 Time
2 Times
3 Times
4 or More Times
113
Individual #5 Total Number Of Months Experiencing Homelessness In The Last 3 Years?* This field is required.
114
Individual #5 Do You Have Health Insurance?* This field is required.
Medicaid/OHP
Medicare
State Children HI
Veteran (VHA)
From Employer
COBRA
Private Pay
Indian Services
No
Do Not Know
Prefer Not To Answer
115
Individual #5 Do You Have A Disabling Condition? Check All That Apply* This field is required.United States Department of Housing and Urban Development requires we ask this question
Alcohol Use Disorder
Drug Use Disorder
Developmental
HIV/AIDS
Mental Health Disorder
Physical
Chronic Health Condition
None
116
Individual #5 If Applying For Kelly Shelter, Can You Use A Top Bunk?
YESNO
117
Individual #5 How Long Have You Resided In Jackson County?* This field is required.
118
Individual #5 Do You Receive Food Stamps? (SNAP EBT)
YESNO
119
Individual #5 Enter Monthly Amount Received (SNAP EBT)* This field is required.
120
Individual #5 Do You Receive WIC?* This field is required.
YESNO
121
Individual #5 Enter Monthly Amount Received For WIC* This field is required.
122
Individual #5 Do You Receive Any Reliable Income Each Month?* This field is required.
YESNO
123
Individual #5 Enter Monthly Income Amount Received* This field is required.
124
I Give My Permission To Share This Data With Local Agencies To Better Provide Me Care* This field is required.
YESNO
125
Signature of Head of HouseholdBy signing this application I understand that the information I provide will be entered into the ServicePoint HMIS database and my records will be updated as I receive services.
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