Crisis Response PRG : Hotels, Clothing, Gift Card

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STOP! DID YOU FILL OUT THE CLIENT INTAKE FORM ?* This field is required.Before requesting services you must fill out the client intake form or your application WILL NOT be processed. If you have not already done so , please copy and paste this link into your browser and return to this application once complete. Link: https://form.jotform.com/Ark_Refuge/client-evaluation-form
YESNO
2
Application Submission Month* This field is required.This application is a ONE-TIME benefit on an ANNUAL basis. Please select from the drop-down list below the month you are submitting this application. Previous recipients must wait 12 months before re-applying
Please Select
Please Select
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
3
Referral Source* This field is required.
Please Select
Please Select
1. Friend/Relative
2. Oakland Elizabeth House
3. Report A Victim (Website Form)
4. Heritage Hospital - Sacramento
5. Street Outreach Team ( Foot Canvass)
6. Called Crisis Hotline (+1-866-676-0070)
4
Which Category Best Describes You* This field is required.If none, your are not eligible to receive these services.
Victim of a Crime
Housed DV Victim- Single Adult
Housed DV Victim- Family
DV Victim Homeless with a Family
DV Victim - Homeless withOUT a Family
Elder Abuse ( Over age of 60)
None of the above
5
If you selected a "Housed" category, explain your necessity for temporary housing. * This field is required.Your application will NOT be processed without an explanation.
If you did not select a housed option in the previous question , enter Not Applicable (N/A).
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Client Full Name* This field is required.Legal name on verifiable documentation.
First Name
Last Name
7
Date of Birth* This field is required.What is your date of birth?
Date
Year
Month
Day
8
Phone Number* This field is required.What is your telephone number?
Area Code
Phone Number
9
Email* This field is required.
example@example.com
10
County* This field is required.What county are you currently in?
11
Client Hotel Check In Date / Time* This field is required.What date are you checking in?
12
Requested Resources* This field is required. You are only allowed one selection. Enter Coupon code ArkofRefuge at checkout for a 100% discounted rate. Vouchers are $190 per night including taxes and fees.
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My Bag
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My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Occupancy and Tourism TaxesUSD
SubtotalUSD
Total costUSD
3- Night Hotel Room Voucher (s) Available for redemption ONLY in the State of California.
$570.00Edit
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4- Night Hotel Room Voucher (s) Available for redemption ONLY in the State of California.
$760.00Edit
Back
5- Night Hotel Room Voucher (s) Available for redemption ONLY in the State of California.
$950.00Edit
Back
6- Night Hotel Room Voucher (s) Available for redemption ONLY in the State of California.
$1,140.00Edit
Back
7- Night Hotel Room Voucher (s) Available for redemption ONLY in the State of California.
$1,330.00Edit
Back
Emergency Visa Gift CardTo receive the emergency visa gift card that comes with the hotel voucher program please select from available quantity below. Delivered via USPS to hotel address or at time of client accompaniment to Hotel Registrar.
$150.00Edit
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Quantity
Courtesy Emergency ClothingAs a courtesy to all hotel voucher clients, we provide a one size fits all Undergarments, a Unisex Shirt, Socks, a Baseball Style Hat, Close-Toed Flip Flops, or Slip On Crocs or a burlington coat factory gift card. Select from the available quantity below.
$194.17Edit
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5
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8
9
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Quantity
Enter Coupon
Total cost $0.00
13
If you have a future check in date, explain why your "emergency" can wait?
14
Uber Pick Up/Date* This field is required.What date and time are you getting picked up by Uber or received your Uber Voucher?
Date
Year
Month
Day
15
Uber Pick-Up Address* This field is required.This is the address you will be picked up from .
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
16
Uber Credit/Gift Card Delivery Method* This field is required.
Please Select
Please Select
In-Person (Physical Card)
Email on Application (Electronic Card)
17
I Client Full Name * acknowledge that the Ark of Refuge is providing temporary housing, as well as additional resources to myself and/or family. I confirm each single adult has been housed separately and each couple jointly.

Due to the status of my social and economic circumstances, anonymity is crucial. Therefore I agree to have the hotel room reserved under the Company or Company Representatives' name.

I assert I have been provided a $150 Visa Gift Card to use for additional fees and necessities as well as emergency clothing, transportation and/or donated food.
18
Client Identification Verification * This field is required.Give phone back to staff for upload of photo.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Medicaid Card, EBT Card, SSN, ID, letter from a municipality or shelter confirming Identity or photo image.
Cancelof
19
Client Signature* This field is required.
Clear
20
Invoice ID
21
** STAFF ONLY - Client Hotel Voucher Duration* This field is required.Select length of requested hotel voucher.
Please Select
Please Select
1-Day Hotel Voucher
2-Day Hotel Voucher
3-Day Hotel Voucher
4-Day Hotel Voucher
5-Day Hotel Voucher
6-Day Hotel Voucher
7-Day Hotel Voucher
22
** STAFF ONLY -Client Priceline Confirmation Number * This field is required.Name of Client Hotel
23
** STAFF ONLY -Client Hotel Reservation Number * This field is required.Name of Client Hotel
24
** STAFF ONLY -Name of Client Reserved Hotel * This field is required.Name of Client Hotel
25
** STAFF ONLY -Address of Client Reserved Hotel * This field is required.Address of Client Hotel
Street Address
Room Number
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
26
** STAFF ONLY - Emergency Clothing Distribution Checklist* This field is required.Listed below are the items to be included in the emergency clothing package please check off each item as you place it in a bag for the client.
27
I Staff Full Name * acknowledge that I am booking this reservation in accordance with the travel policy and company monthly motel voucher distribution agreement for the applicable month. This electronic signature is a Binding agreement between both Client- and Ark Of Refuge.
28
Receipt Upload(s)* This field is required.Upload all client receipts here.
Drag and drop files here
Select files to upload
Cancelof
29
Staff Signature* This field is required.
Clear
Should be Empty: