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Registration Form

Please complete this application for a followup interview with caseworker.

(Need Phone and/or Email Address)

Hope Restored Missions

Office Hours
Monday-Friday 10AM-4PM
1947 K Ave. Ste B100 Plano 75074

214-501-2183

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PERSONAL DATA

First

Middle

Last

Date of Birth

MM/DD/YYYY

Phone

Email

Emergency Contact

Emergency Phone

Emergency Email

Veteran

Yes
No

Disabled

Yes
No

Domestic Abuse Victin

Yes
No

Gender

Male
Female
Transgender
Other

Race

African American/Black
Caucasian/White
Asian
Hawaiian/Pacific Islandr

Ethnicity

Non-Hispanic
Hispanic/Latin

Marital Status

Single
Married
Divorced
Widowed

Family Type

Individual
Single Parent/Female
Single Parent/Male
Two Parent

Preferred Language

English
Spanish

Number in Family

Head of Household

Self
Spouse

Have Transportation (Vehicle)

Yes
No

Other Family Members

Name

Date of Birth

Relationship

Gender

Male
Female
Transgender
Other

HOUSING

Last Permant Address (House/Apartment)

Address Line 1

Address Line 2

City

State

Zip Code

Stayed Last Night At

My House/Apt
Friend/Family
Motel
Car/Train
Hospital/Jail
Shelter
Outside
Other

If Currently Homeless - How Long

< 1 Month
2-6 Months
1-2 Years
2-3 Years
> 3 Years

Relationship of Phone

EMPLOYMENT

US Citizen

Yes
No

Felony Conviction

Yes
No

Currently Employed

Yes
No

Work Permit (Non-Citizen)

Yes
No

When

< 2 years
< 5 years
< 10 years

Income/Month

Education

0-8 years
9-12 (non HS Grad)
HS Grad/GED
College (Non Grad)
College Grad
Graduate Degree
Voc/Tech (completed)

Benefits Received

TANF
SNAP (Food Stamps)
SSI
SSDI
SS
Pension
Other

Health Insurance

None
Medicare
Medicaid
Private

Income/Month

ASSISTANCE

HRM Assistance Desired

Food / Hygiene / Clothing
ID Documents / Mailbox
Housing
Employment
Medical / Rx
Mental Health
Workforce Training
Other

Describe Your Current Situation / Needs

Release of Information

I authorize Hope Restored Missions (HRM) to share my registration information with Housing Forward or other member agencies for the purposes of monitoring compliance with funding requirements and improving services to those in our community who are unhoused, or who are at risk of being unhoused in Collin and Dallas Counties.

Client Signature (Write/Type)