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Intake Application
First Name
Last Name
Email
Phone Number
Birthday
Mailing Address Street
City
State
Zip Code
Marital Status
Single
Married
Widowed
Divorced
Separated
Referred By
Briefly Describe Your Situation
List anyone residing in your household. Name, dob, Relation, Marital Status. If none, put N/A.
Do you have any relatives living in town?
Yes
No
If no, where are they located? If you do not have any relatives, please put N/A
Relatives - Please list Name, Phone or other contact info, and relation. If no relatives put N/A.
Previous Residence - Please list 5 yrs of residence. Include move in/ out dates, address, landlord name and contact info, and your reason for moving.
Select all assistance you have applied for to aid your situation
IWV Family Resource Center
College Community Services
Human Service
Salvation Army
VA
Women's Center
Other
Do you attend church?
Yes
No
If yes, where, pastor's name, how long have you been attending and how often?
Employment Status - Check all that apply
Unemployed
Full Time Employed
Part Time Employed
Full Time Student
Part Time Student
Retired
Disabled
If disabled, please explain your disability.
Employment History - Please list 5 years of employment. Include Start/End Date, Employer Name and contact info, reason for leaving.
Do you have the financial ability to pay for the program? Cost of the program is $1100, we provide some meals and have a partnership with College Community Services in which you may be able to receive a county referral voucher. Financial ability does not mean disqualification, some scholarships, both full and partial, are available. Applicants are encouraged to seek financial assistance from family and friends before applying for scholarships
Yes
No
Maybe
Have you been convicted of a misdemeanor or a felony?
Yes
No
If yes, please explain
Are you currently on parole or probation?
Yes
No
If yes, please explain
List all diagnosed and undiagnosed physical or mental health conditions / concerns. If none put N/A
List all prescribed, unprescribed, and over-the-counter medications you are taking. If none put N/A
Do you have medical? or any other insurance?
Yes
No
Release of Information - hereby authorize the release of information to Refuge and the participating church(es) to receive the assistance I am requesting. I further certify that the information I have stated is true and correct and that all income is reported. I understand that Refuge and the participating church(es) will verify the information contained in this application and that the deliberate misrepresentation of information will result in the denial of assistance and/or services. I hereby give permission to Refuge and the participating church(es) to discuss my case with other agencies, businesses, churches, attorneys, individuals, and others deemed necessary to verify the application information and/or identify additional sources of assistance. I understand that the information contained herein and the information pertaining to this case is stored in an online database, which is accessible to IWV churches, organizations in the community who offer financial assistance programs, and the Ridgecrest Police Department. I further understand that all of the information will remain as private as possible within these entities. I have read, understand, and agree to the above policies regarding the Release of Information. Type name below.
Date Signed
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