Keys of Hope Application

1.) Full Name

First NameMiddle NameLast Name

2.) Date of Birth

Date

3.) Are you currently unhoused? This applies if you are lacking a fixed, permanent residence. Examples may be sleeping on your friend's couch or in your car.

4.) Please provide the address where you stayed last night. This can be your home, a friend or family member’s place, or another location where you are staying temporarily.

Street Address

CityStateZip CodeCountry

5.) Please provide a short description of this address.

E.g., My friend's place, my car, an emergency shelter, park bench, on the street, etc.

6.) Are you a US Citizen, or have eligible legal immigration status verification?

7.) Can you provide proof of your identity?

8.) Do you have children or other dependents that live with you either part- or full-time?

9.) What is your monthly income (in USD)?

Include ALL forms of income such as: 1) employment wages, 2) SSI/SSDI, 3) unemployment benefits, 4) pension/retirement, 5) veterans/military benefits, 6) grants, scholarships, stipends, student loans, or financial aid that can be used for living expenses, 7) monthly trust fund/guardianship allowances, and/or 8) independent living allowances, extension of foster care program funds, and/or education and training voucher (ETV) program funds

10.) Can your income be verified?

11.) Have you been sober for the past 90 days?

12.) Are you able to function in a group living environment?

Other

13.) Have you been in the Keys of Hope program before?

14.) Were you referred to this program?

15.) If yes to being referred, please provide referral name/agency.

Write N/A if you answered "NO"

16.) Please provide the best way to reach you.

Phone number or email address