Interim Housing Request

"*" indicates required fields

Name

First Middle Last

Date of Birth

Social Security Number

Gender

Phone

What are you applying for?*

New Leaf – Interim Housing/shelter for individuals/couples

Almost Home – Interim Housing/Shelter for families with children

Genesis 2 – Men’s recovery sober living

How many in Household?*

# of Adults (18+)*

# of Children*

List all other members of your household, including birthdates, SSN, relationship to Head of Household and Gender

Name	Date of Birth (*Leave blank if unknown)	Social Security Number (*Leave blank if unknown)	Relationship to the Head of Household	Gender	Actions

There are no Household Members.

What county are you currently residing?

Montcalm

Ionia

Other

If you selected other, which county?

Where did you sleep last night?*

If Other, please describe

Where are you sleeping tonight?*

If Other, please describe

Emergency Contact Name:

Emergency Contact/Support Person

Emergency Contact Person's Phone:

Emergency Contact/Support Person

I certify that all the information on this application is accurate and complete to the best of my knowledge.*Yes I authorize Have Mercy to complete a criminal background check for all adults in the household.*

Yes

Agency Agreement

I certify that all the information on this application is accurate and complete to the best of my knowledge. I authorized Have Mercy to complete a criminal background check for all adults in household. I agree with the agency consent below: CONSENT FOR AGENCY SHARING-HOUSING PROGRAMS: I understand that signing below is giving my consent allowing pertinent information listed to be shared among authorized personnel and partnering agencies to assist with provision of shelter and housing placement. All agencies, relevant to my shelter and housing needs, where I am receiving services may update information as I provide additional or new information. The purpose of sharing my information is to better coordinate shelter/housing needs for my household. This consent may be revoked at any time, through a written statement from me.*

Yes, I Agree

Your Name*

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Name

First Last

Name

First Last

Name

First Last