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Family Application Form
Credit Report
Family Application
Date
Personal Information
Adult 1 Name
*
First
Adult 1 Name
*
Last
Adult 1 Date of Birth
*
Adult 1 Phone Number
*
Adult 1 Email
*
Adult 1 Social Security #
*
Adult 2 Name
First
Adult 2 Name
Last
Adult 2 Date of Birth
Adult 2 Phone Number
Adult 2 Email Address
Adult 2 Social Security #
Marital Status
*
Single
Engaged
Married
Living Together
Other
Divorced
Marital Status
Child 1 in Household
*
First and Last
Child 1 Date of Birth
*
Month, Day and Year
Name of School/Daycare
*
Cost of Daycare per Week
Cost per child
Child 2 Name
First and Last
Child 2 Date of Birth
Month, Day, and Year
Name of School/Daycare
Cost of Daycare per Week
cost per child
Child 3 Name
First and Last
Child 3 Date of Birth
Name of School/Daycare
Cost of Daycare per Week
cost per child
Child 4 Name
First and Last
Date of Birth
Month, Day and Year
Name of School/Daycare
Cost of Daycare per Week
Cost per child
Child 5 Name
First and Last
Date of Birth
Month, Day, and Year
Name of School/Daycare
Cost of Daycare per Week
Cost per child
Child 6 Name
First and Last
Date of Birth
Month, Day and Year
Name of School/Daycare
Cost of Daycare per Week
Cost per child
Are you currently pregnant or is there a possibility that you are?
*
Yes
No
When is your due date?
Are all of your children currently in your care?
*
Yes
No
Please explain your relationship to the children in your household.
*
Do any of your children have any mental, emotional, and/or physical problems?
*
Yes
No
Please explain.
*
If dirovced, How long have you been divorced? Do they have custody rights?
*
If single or divorced, Where is dad/mom of children? Does he have contact or custody? Do you receive child support? If so, how much?
*
If your children have any disabilities are they being properly treated?
*
Housing
Family's Current Address
Family's Current Address
Family's Current Address
Family's Current Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Current Living Situation
*
Own
Rent
Living with Friend
Shelter
Homeless
Where were you living prior to being homeless and what events led up to you being homeless?
*
Please explain your current living situation
*
i.e. Behind on rent, unsafe living situation, possible eviction
If homeless, How long have you been homeless?
*
If currently in housing, When is your lease up?
*
Rent or Mortgage per Month
How much is your monthly rent or mortgage payment?/Are you behind?/If so, how far behind?
Is there anyone living in the home with you other than the people listed on this application?
*
Yes
No
Please explain.
*
Who, Relationship to you, how long have you lived together? etc.
Evictions
*
When? Where? How Much?
Do you receive housing assistance?
*
Yes
No
Please Explain
*
How much? Who from?
Do you have any pets?
*
Yes
No
Please list the type of animal, weight, and if it is an ESA registered animal.
*
Employment
Which best describes the educational level of Adult 1?
*
Elementary School
Some High School
GED
High School Graduate
Some College
College Graduate
College Master’s Degree
Doctoral / Medical / Legal Degree
Does Adult 1 wish to go back to school?
*
Yes
No
Is Adult 1 employed?
*
Yes
No
Please list the following: Employer/Address/Phone Number/Wage/How long have you been employeed at this job
Please explain how long you have been unemployed and why?
*
What was your last job? How long were you at that job and why did you lose it?
*
Which best describes the educational level of Adult 2?
Elementary School
Some High School
GED
High School Graduate
Some College
College Graduate
College Master’s Degree
Doctoral / Medical / Legal Degree
Does Adult 2 wish to go back to school?
*
Yes
No
Is Adult 2 employed?
Yes
No
Please list the following: Employer/Address/Phone Number/Wage/How long have you been employeed at this job
Please explain how long you have been unemployed and why?
*
What was your last job? How long were you at that job and why did you lose it?
*
Transportation
Do you have a car?
*
Yes
No
Other
Do you have a car?
Vehicle Year
Make
Model
License Plate #
Auto Insurance Carrier
Cost Per Month
Do you have a car loan?
Yes
No
Details
Cost per month/total loan amount/past due/other info
Medical Background
Does Adult 1 have any mental, emotional, and/or physical health problems?
*
Please explain.
List any medications for Adult 1.
Is Adult 1 under a doctor's care?
*
Yes
No
Please explain. When were you diagnosed? Are you being treated for your diagnosis and how long have you been on treatment?
Has Adult 1 ever experienced physical, sexual, or emotional abuse?
*
Yes
No
Please explain. When did it occur? Have you seeked proper treatment? Where?
Has Adult 1 been involved in counseling or therapy?
*
Yes
No
Please explain. Where and for how long?
If Adult 1 is not currently in counseling, are they willing?
*
Does Adult 2 have any mental, emotional, and/or physical health problems?
Please explain.
List any medications for Adult 2.
Is Adult 2 under a doctor's care?
Yes
No
Please explain. When were you diagnosed? Are you being treated for your diagnosis and how long have you been on treatment?
Has Adult 2 ever experienced physical, sexual, or emotional abuse?
Yes
No
Please explain. When did it occur? Have you seeked proper treatment? Where?
Has Adult 2 been involved in counseling or therapy?
Yes
No
Please explain. Where and for how long?
If Adult 2 is not currently in counseling, are they willing?
Benefits and Finances
Do you receive benefits?
*
Yes
No
Benefits your family is currently receiving
Salary
TANF
SSI
Social Security
WIC
Food Stamps (SNAPS)
Medicaid
Medicare
HUD/S-8 Housing
Retirement Benefits
Military Benefits
Medical Insurance
Dental Insurance
Child Support
Disability
Does Adult 1 have health insurance?
Yes
No
Adult 1 Carrier
Does Adult 2 have health insurance?
Yes
No
Adult 2 Carrier
How much you are receiving from each benefit
Total approximate monthly income
*
Include wages and child support
Where are all of the places you receive monthly income from?
*
Monthly Grocery Expense
*
Monthly Utilities
*
Credit Card Debt & Monthly Expense
*
Monthly Cell Phone Expense
*
Other Expenses
*
Please Describe
Total Debts Owed
Please describe what and how much is owed for each item.
Has your family or any member of your family previously had any type of assistance from another organization / group / counseling?
*
Yes
No
Who assisted, and was it helpful?
What other organizations have you received help from?
*
If you are accepted into our program and needing financial assistance, we will ask for you to take part in a financial program that is linked to your bank account to help with budgeting. Are you willing to comply with this?
*
Yes
No
Additional Information
If there are charges or previous arrests, please explain what happened.
*
Have you or any other extended family members or relatives been in prison, arrested, charged or have or had pending or dropped charges with any tickets, crimes, misdemeanors, felonies, or involved in any other legal matters that we should know about?
*
Yes
No
Describe the Charges
Please explain why CPS was involved with your family and the current status of the CPS case.
*
Is their current or past CPS involvement with your family?
*
Yes
No
Please explain.
*
Are you at risk of CPS involvement, or having your kids removed from your care?
*
Yes
No
Please explain.
*
Please provide any other useful information that was not included in this application.
Needs
If there were 3 things you could have right now to help you be self sufficient, what would those be?
*
What services do you believe you need to achieve and sustain self-sufficiency?
*
What are the main problems that you or your family are dealing with at this time?
What is your faith background?
*
Grace Like Rain commits to serving families in crisis through the use of professionals and volunteers willing to extend God’s grace and unending love. If approved for our program, a volunteer family coach and Family Case Manager are assigned to help you work towards accomplishing your family's established goals. A plan will be created with achievable short and long term goals that will help you work towards stability and self-sufficiency. The coach will motivate, support and walk alongside the parents helping them work towards positive life changes. Counseling, parenting classes, budgeting classes, government aid, housing, employment, education, life skills, Bible studies, and support groups are among many possible directions the coach will guide the family towards. Please explain why you would be a good fit for our ministry.
*
Please explain why you would be a good fit for our ministry.
If you are human, leave this field blank.
Who We Are
About Us
Staff & Board
Partners
Donate
What We Do
Programs
Love First
Events
Apply
Blog
Get Involved
Donate
Partner with Us
Volunteer
Events
Needs
Shop
For You
For Others
Contact Us
Donate