Application for Interfaith Hospitality Network (IHN) Temporary Shelter Program

Prerequisites - A response of "No" for the next six questions is a disqualification from the IHN program. Are there children under 18 currently in your legal and physical custody? *

Yes

No

Do you attest that you have not experienced houselessness more than once as an adult? (Family Promise of COS' mission is to serve situationally unhoused families) *

Yes

No

Do you attest that you have never been convicted of domestic violence, child abuse, or assult? *

Yes

No

If you have a pet, will you board it if accepted? If no pet, do you attest not to bring a pet with you if accepted? (No pets allowed to inclue ESAs) *

Yes

No

If accepted, do you commit to sobriety throughout the program (to include alcohol and marijuana)? *

Yes

No

Do you authorize Family Promise of COS to run a Background Check on all applicants over 18 years of age? *

Yes

No

Head of Household – Personal Information

First Name

Last name

Primary Email

Primary Phone Number

Alternate Email

Alternate Phone Number

Date of Birth

Month

Day

Year

Please share any personal details you would like us to consider (e.g. special needs or requirements). If non, please enter "NA"

Family Member 1 – Personal Information

Family Member 1: First Name

Family Member 1: Last Name

Family Member 1: Date of Birth (Mo/Day/Year)

Please share any personal details you would like us to consider (e.g. special needs or requirements). If non, please enter "NA"

Family Member 2: Personal Information

Family Member 2: First Name

Family Member 2: Last Name

Family Member 2: Date of Birth (Mo/Day/Year)

Please share any personal details you would like us to consider (e.g. special needs or requirements). If non, please enter "NA"

Family Member 3: Personal Information

Family Member 3: First Name

Family Member 3: Last Name

Family Member 3: Date of Birth (Mo/Day/Year)

Please share any personal details you would like us to consider (e.g. special needs or requirements). If non, please enter "NA"

Family Member 4: Personal Information

Family Member 4: First Name

Family Member 4: Last Name

Family Member 4: Date of Birth (Mo/Day/Year)

Family Member 5: Personal Information

Family Member 5: First Name

Family Member 5: Last Name

Family Member 5: Date of Birth (Mo/Day/Year)

Please share any personal details you would like us to consider (e.g. special needs or requirements). If non, please enter "NA"

Emergency Contact

First Name

Last Name

Phone

Email

Residential Address (Street Address, Apartment/Ste, City, State, ZIP

Relationship

Shelter Program Application Questions

Using as much detail as possible, how will you use this program to change your current situation in less than 90 days?

How long have you been experiencing homelessness?

How many times have you experienced homelessness in your life?

Do any family members have medical concerns?

Yes

No

If You Answered "Yes", please explain in detail

Tell us about your current income sources

What is your monthly income from a job or employment?

Food Assistance/SNAP Income

Unemployment Benefits Income

TANF Income

Medicare/Medicaid Income

Social Security Income

Disability Income

Child Support/Alimony Income

Savings Account Total

Checking Account Total

Please share your last address (Street, Apt/Ste # City, State, ZIP)

Referred by:

For the Family Promise of Colorado Springs to provide you with the best possible services, we are required to collect information about you and your family. This information will be entered into a computer and allow us to keep track of your information and the services we provide. IHN is required by law to protect the privacy of your information, inform you of your rights, and tell you how we keep your information private.

I have read the disclosure statement and my questions have been answered. I hereby certify that, to the best of my knowledge, the provided information is true and accurate

Signature

Signature field is empty.

Date

Month

Day

Year