New Service Application Form
Rebuilding Together Rogue Valley
Lead Status
Who is filling out this form?
*
Client
Relative, Friend or Caregiver
Who is the primary contact?
Client
Relative, Friend or Caregiver
Primary Contact
First Name
Last Name
Relationship to Client
Relative
Friend
Caregiver
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Client Name
*
First Name
Last Name
Client Gender
Please Select
Man/male/masculine
Woman/female/feminine
Transgender
Non-binary
Other / Non-Conforming
Client Race
Please Select
White
African American
American Indian
Hispanic / Latino
Native Hawaiian / Pacific Islander
Asian
Other
Client Email Address
example@example.com
Caregiver (If Applicable)
First Name
Last Name
Client Phone Number
Please enter a valid phone number.
Client DOB
*
-
Month
-
Day
Year
Date
Current Insurance
Please Select
None
Unknown
Medicare
Medicaid
AllCare
OHP
Care Oregon
Member ID (If Known)
Street Address
*
Apartment, suite, etc
City
*
State/Province
ZIP / Postal Code
*
Move-in date
Home Ownership
Rent
Own
Other
Lease Agreement
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Landlord Approval Letter
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Proof of Home Ownership
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have owners permission if applicable?
*
Yes
No
Are there children under 6 in the home?
*
Yes
No
Do you live in a mobile home?
*
Yes
No
If yes, Do you rent or own your own slab?
*
Rent
Own
If Yes, is the mobile home on wheels?
Yes
No
Repairs needed?
*
Anything else we should know?
Submit Application
Should be Empty: