Edna Raine Wardlaw Coker Women's Transition Center
Please fill this application out to the best of your ability. We will respect your confidentiality. Please keep in mind that residents must be employed, and our residents must return by 7:30 pm each evening. NOTE: You will NOT qualify at this time if: You are unemployed, work less than 20hrs per week, lack employment verification, or can't make 7:30pm curfew
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date Picker Icon
Phone Number
-
Area Code
Phone Number
E-mail
example@example.com
Are you employed?
Yes
No
Do you work at least 20 hours each week?
Yes
No
Can you provide a pay stub or letter to verify employment?
Yes
No
The program curfew is 7:30 pm. If you cannot arrive at the church at 7:30 pm., you won't qualify. Can you make our 7:30 pm curfew every day?
Yes
No
Do you have children with you? We CANNOT accommadate children at our facility.
Yes
No
Social Security Number -- last 4 digits
Are you over the age of 18?
Yes
No
How did you hear about this program?
Marital Status
Single
Married
Divorced
Widowed
Children?
Yes
No
Ages of your children
Do you have the following:
Picture ID
Social Security Card
Birth Certificate
Where did you sleep last night?
What events led to your needing temporary housing?
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Full-time or Part-time
Full-time
Part-time
How many hours do you work weekly?
What is your schedule?
High School Attended
Did you graduate?
Yes
No
GED?
Yes
No
College Attended
Major
Did you receive a diploma, certificate or degree?
Yes
No
College Attended
Major
Did you receive a diploma, certificate or degree?
Yes
No
College Attended
Major
Did you receive a diploma, certificate or degree?
Yes
No
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Drug and alcohol treatment programs you have been in or are in now:
List and give dates for all major hospital stays for physical and mental health issues:
List ongoing expenses: (Be Specific)
List outstanding debt:
List all sources of income including food stamps:
Are you currently on disability assistance?
Yes
No
Have you applied for disability and been denied?
Yes
No
List any convictions and/or jail or probation served:
Have you served in the military?
Yes
No
If so, list the branch and service dates:
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Relative who can be notified in class of emergency:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Friend who can be notified in class of emergency:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Phone Number
-
Area Code
Phone Number
Three references: They may be anyone you know including employers, family, friends, coworkers, etc.
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relation
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relation
Name
First Name
Last Name
Relation
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Complete Employment History for the Last Five Years *REQUIRED
Start Date
-
Month
-
Day
Year
Date Picker Icon
End Date
-
Month
-
Day
Year
Date Picker Icon
Company
City, State
Position
How did this position end?
You quit
You were offered a better position
Health conditions
Had a baby
You were terminated
You were laid off
You were incarcerated
Other
Explain other
Start Date
-
Month
-
Day
Year
Date Picker Icon
End Date
-
Month
-
Day
Year
Date Picker Icon
Company
City, State
Position
How did this position end?
You quit
You were offered a better position
Health conditions
Had a baby
You were terminated
You were laid off
You were incarcerated
Other
Explain other
Start Date
-
Month
-
Day
Year
Date Picker Icon
End Date
-
Month
-
Day
Year
Date Picker Icon
Company
City, State
Position
How did this position end?
You quit
You were offered a better position
Health conditions
Had a baby
You were terminated
You were laid off
You were incarcerated
Other
Explain other
Start Date
-
Month
-
Day
Year
Date Picker Icon
End Date
-
Month
-
Day
Year
Date Picker Icon
Company
City, State
Position
How did this position end?
You quit
You were offered a better position
Health conditions
Had a baby
You were terminated
You were laid off
You were incarcerated
Other
Explain other
Start Date
-
Month
-
Day
Year
Date Picker Icon
End Date
-
Month
-
Day
Year
Date Picker Icon
Company
City, State
Position
How did this position end?
You quit
You were offered a better position
Health conditions
Had a baby
You were terminated
You were laid off
You were incarcerated
Other
Explain other
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Complete Housing History for the Last 5 Years
Move In Date
-
Month
-
Day
Year
Date Picker Icon
Move Out Date
-
Month
-
Day
Year
Date Picker Icon
City, State
Why did you move?
Lease was up
Evicted
Owners asked me to leave
Other
Explain other
Were you the owner or lease holder?
Yes
No
Move In Date
-
Month
-
Day
Year
Date Picker Icon
Move Out Date
-
Month
-
Day
Year
Date Picker Icon
City, State
Why did you move?
Lease was up
Evicted
Owners asked me to leave
Other
Explain other
Were you the owner or lease holder?
Yes
No
Move In Date
-
Month
-
Day
Year
Date Picker Icon
Move Out Date
-
Month
-
Day
Year
Date Picker Icon
City, State
Why did you move?
Lease was up
Evicted
Owners asked me to leave
Other
Were you the owner or lease holder?
Yes
No
Move In Date
-
Month
-
Day
Year
Date Picker Icon
Move Out Date
-
Month
-
Day
Year
Date Picker Icon
City, State
Why did you move?
Lease was up
Evicted
Owners asked me to leave
Other
Were you the owner or lease holder?
Yes
No
Move In Date
-
Month
-
Day
Year
Date Picker Icon
Move Out Date
-
Month
-
Day
Year
Date Picker Icon
City, State
Why did you move?
Lease was up
Evicted
Owners asked me to leave
Other
Were you the owner or lease holder?
Yes
No
Submit
Should be Empty: