Shelter Application Form Shelter Application "*" indicates required fields What county are you currently residing?* Montcalm Ionia Gratiot Isabella Shiawassee Other If you are interested in a substance abuse recovery bed in Montcalm County, proceed with the application. Otherwise please call 211 for assistance in your county. Name First Middle Last Date of Birth Social Security Number (last 4 digits only) GenderMaleFemaleOther than Male or FemaleRaceAmerican Indian, Alaska Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanNative Hawaiian or Pacific IslanderWhiteDon’t KnowOtherEthnicityNon-Hispanic/Non-LatinHispanic/LatinDon’t KnowHiddenGender – old PhoneEmail What are you applying for?* Shelter because of domestic violence (with partner) Shelter for individuals Shelter for families with children Men’s recovery sober living (located in Montcalm county) 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) Relationship to the Head of Household Gender Actions Edit Delete There are no Household Members. Add Household Member Maximum number of household members reached. HiddenIf you selected other, which county? Where did you sleep last night?* Vehicle Outside Tent Motel / Hotel Friend or Family Home Other If Other, please describe Where are you sleeping tonight?* Vehicle Outside Tent Motel / Hotel Friend or Family Home Other If Other, please describe Emergency Contact Name: Emergency Contact/Support PersonEmergency 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. I authorize the shelter provider to complete a criminal background check for all adults in the household.* Yes Agency AgreementI 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* CAPTCHA Δ{{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting… Copyright 2023 Central Michigan Local Planning Body Coordinated Entry Program Website designed by Addis Enterprises
