Do you have reliable transportation?*
If working with a housing provider, please provide their contact information.
Please fill out the following for each child that will be living with you. ** If you do not have children, please leave blank.
Are you enrolled with Child Works/ELRC (Early Learning Resource Center)?
Have you ever been a participant in our program before?*
Have you ever experienced homelessness before?*
Do you have any evictions?*
If yes, how many, if none please select none.*
Are you pregnant or think you may be?*
Are you currently using or have used in the last 12 months any illegal substances or are you struggling with alcohol?*
Were you recently in a hospital or rehab?*
Will you need ongoing care?
Do you require any ADA accommodations?*
Do you have any past substance or alcohol abuse?*
Do you have any mental health diagnoses?*
Are you currently fleeing domestic abuse?*
Do you have a PFA against someone?*
Is there a PFA against you?*
Financial and Legal History
Are you currently employed?*
Please list what you receive MONTHLY for each category below.
Do you have a criminal background (charges or convictions)?*
Do you currently have any arrest warrants?*
Were you recently incarcerated?*
Are you on probation or parole?*
Are you a resident of Lancaster County?*
