Application For Assistance | Foster Care In The U.S

Assistance Needed*

Down payment assistance (for homeless/living in shelter)
Food
Household Items (Furniture, beds, cooking utensils etc.)
Medical/Dental/Vision Assistance
Medication Costs
Rent Assist
Transportation ( Gas Card, Bus tokens etc)
Utilities

Assistance Needed*

Down Payment Assistance. How much?	Rent Assistance. How much?	Utility Assistance. How much?

Current Living Situation*

Today's Date

Preferred Language

First Name*

Last Name*

Current Address:*

Zip Code:*

Contact Phone:*

Contact Email (must be accessible to you):*

Date of Birth:*

Were you ever in foster care?*

Status*

Status Continued*

Employer Information

Employer Name Employer Address

Employer Phone

Housing Information

Landlord Name Landlord Address

What is your monthly rent amount?*

Are you currently receiving assistance with your bills?*

Yes
No

If yes, who is currently assisting you?*

How Were You Referred To Our Organization For Services?*

HMIS (Homeless Management Information System)*

Homeless Management Information System (HMIS) Notice of Privacy Practices
Effective 10/2021 Version 3.0

The purpose of this notice is to explain to you why we collect personal information from you and refer you to the HMIS Statement of Privacy Practices for additional information regarding how this information may be used or disclosed.

When you request services from this agency, we enter information about you, and members of your family, into a computer system, called the Homeless Management Information System (HMIS). We collect personal information directly from you for reasons that are discussed in our HMIS Statement of Privacy Practices. We may be required to collect some personal information as required by the United States Dept of Housing and Urban Development (HUD), by law, or by organizations that this agency funds to operate this program. The personal information we collect is important to run our programs, to improve services for homeless, or those at risk of homelessness, individuals and families
We may use or disclose your information to provide you with services. We may also use or disclose your information to comply with legal and other obligations. We assume that you agree to allow us to collect information, and to use or disclose it, as described in the HMIS Statement of Privacy Practices.

You can inspect personal information about you that we maintain, as provided in the HMIS Statement of Privacy Practices. You can also ask us to correct inaccurate or incomplete information. Please contact the Case Manager, agency Site Administrator, or Executive Director of the agency who entered the data to make this request.

Please read the HMIS Statement of Privacy Practices for additional information. You will be provided with a copy of the HMIS Statement of Privacy Practices upon request.

I agree to the privacy policy.

CAPTCHA

Housing, Employment & Stability Assistance (HESA) Application

Employer Information

Housing Information