Clone of FPGV Housing Programs Application

Pets
Do you have any pets in your care? If so, please write their breed, size, and age. Please indicate if they are vaccinated and fixed.

Agreements and Understandings
I agree that this application has been completed honestly to the best of my ability.*
Type your initials or name to agree. Agreements are required.
I agree that Family Promise of Gallatin Valley assistance is NOT guaranteed. *
Type your initials or name to agree. Agreements are required.
I agree to participate in all program expectations and submit all documentation requested, in order to be eligible for FPGV assistance. FPGV is not a drop-in service and families must meet program requirements in order to continue. I agree that this application is only eligible for three months. *
Type your initials or name to agree. Agreements are required.
I confirm that I have at least one dependent under the age of 18 years old in my primary custody (50% or more) or that I am pregnant at this time. If you are trying to find housing to reunify with your child(ren), please have your caseworker contact FPGV to confirm reunification efforts.*
Type your initials or name to agree. Agreements are required.
I agree that Family Promise of Gallatin Valley has permission to contact other organizations on my behalf, as well as receive information, in order to be eligible for FPGV assistance. (Consent for Release of Information).*
Type your initials or name to agree. Agreements are required.
By my signature, I authorize release of information on myself and my family for the purpose of assisting me/us to obtain temporary or permanent housing. I understand that the intent and purpose of the sharing of this information is to help various agencies better understand our situation as they assist in serving our needs. I understand that we may be advised to seek treatment for any medical, mental health, chemical dependency and/or abuse issues that may be interfering with our obtaining permanent housing. I understand that the information disclosed shall be limited to information obtained from us through the intake interview process. Only information necessary to provide us with the services we need will be disclosed. This consent is subject to revocation by me/us at any time except to the extent that the program or programs which are to make disclosure have already taken action in reliance on it. If not previously revoked, this consent will terminate one year from the signing of this document or when the case management staff declares the case closed, whichever is sooner. I acknowledge that the information to be released may include material that is protected by federal and/or state law applicable to substance abuse and mental health. I specifically authorize release of all confidential information as set forth herein relating to substance abuse or mental health and specifically authorize disclosure of this confidential information. (Consent for Release of Information).*
Type your initials or name to agree. Agreements are required.
I agree that if I request to participate in an on-site housing program for FPGV (examples: shelter, transitional housing, workforce housing), that FPGV can perform a background check on ALL adults over the age of 18 years old in the family unit. If an adult in my family does not have a social security number, I agree that I will get a reference from a professional in the community - FPGV staff will provide further information if this is applicable to your family. (Consent for Background Check).*
Type your initials or name to agree. Agreements are required.
I authorize Family Promise of Gallatin Valley to contact agencies and individuals for information about me or my family for the purpose of case management and referral.This authorization includes all agencies and individuals with whom I have worked with or may work with. This authorization will be considered a mutual release.The release of content includes, but is not limited to, information regarding entitlements, job performance, financial/credit background, housing status, mental health history, criminal background, legal history, and substance abuse history.The release is limited to the time I am a Guest of the Shelter Program and expires upon my departure from the program. (Consent for Background Check).*
Type your initials or name to agree. Agreements are required.
Is there anything else you would like to include about your family's current situation?
Signature*

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Housing Programs Application

Important Note

Children

Childcare & Schools

Current Housing Situation

Transportation

Pets

Agreements and Understandings