Full Name Date of Birth Email Contact Number Gender Male Female Non-Binary Prefer Not to Answer Preferred Pronouns He/Him She/Her They/Them Other Emergency Contact Name Emergency Contact Phone Number Relationship to Emergency Contact Are you currently experiencing homelessness? Yes No What led to your current situation? Eviction Domestic Violence Financial Hardship Medical Issues Other If Other, Please Specify Do you currently have a safe place to stay? Yes No How long have you been in your current situation? Less than 1 week 1-4 weeks 1-3 months Over 3 months Do you have any medical conditions or disabilities we should be aware of? Yes No If Yes, Please Specify: Are you currently taking any medication Yes No If Yes, Please Specify: Do you have any allergies? Yes No If Yes, Please Specify: Do you require any mobility devices such as wheelchair, cane, or walker? Yes No If Yes, Please Specify: Do you require a translator? Yes No If Yes, Please Specify: Are you able to perform Personal Hygiene Independently? Yes No If No, Please Specify: Are you able to maintain a room in a tidy manner independently? Yes No If No, Please Specify: Are you able to Shower or Bath independently? Yes No If No, Please Specify: Are you able to use the restroom or toileting facilities independently? Yes No If No, Please Specify: Are you able to dress yourself independently? Yes No If No, Please Specify: Are you able to feed or eat independently? Yes No If No, Please Specify: Have you been a client at Cardinal Community House before? Yes No If Yes, did you complete the full program? If you indicated Yes, you were a client with us before, What was the reason for discharge? What services are you seeking? Emergency Shelter Meals / Food Assistance Medical Support Counseling or Mental Health Services Employment Assistance Other If Other, Please Specify: Are there any active restraining orders or legal issues we should know about? Yes No If Yes, Please Specify: Have you ever been asked to leave another shelter? Yes No If Yes, Please Specify: Are you willing to follow all of Cardinal Community House's policies, protocols, and procedures? Yes No Cardinal Community House maintains a zero tolerance policy for Smoking/Nicotine use in or on facility grounds including the facility, park, and parking areas. Failure to follow this procedure will result in immediate disenrollment from the program. Do you agree to not use Nicotine or Smoke anywhere on our properties? Yes No Cardinal Community House maintains a zero tolerance policy for weapons to include guns, knives, sharp metal objects, baseball bats, brass knuckles, or any type of object that can be used to inflict bodily harm on our facility grounds. Weapons must be surrended at the time of arrival. Viiolation of this policy will result in immediate disenrollment from the program. Do you agree to maintain a weapon free zone? Yes No Cardinal Community House maintains a zero tolerance policy for drinking alcohol or having evidence of drinking on it's facility grounds. Violation of this rule will result in immediate disenrollment from the program. Do you agree to not consume alcohol or have evidence of drinking while on facility property? Yes No Cardinal Community House is mandated by State law to secure all medication in our medication room and clients within our facility must strictly follow prescription dosages while in care of Cardinal Community House. All medications including prescription medications must be stored in our secure medication room. Staff members are available around the clock to assist you with gaining access to your medications at appropriate times. Deviation from alloted times and amount will not be tolerated and will result in immediate disenrollment from the program. Do you agree to secure all medications and notify a staff member when it is time for your medication and to not exceed the prescribed limit in both time and dosage? Yes No Cardinal Community House maintains a strict curfew to allow clients that are in process of healing to rest. Our facility doors are closed at 10 pm and will open at 7am. Quiet hours are to be observed during this period of time including weekends. Do you agree to maintain our curfew hours? Yes No Cardinal Community House aims to provide a safe place for those in need of rest and recouperation as our primary mission. Destruction of facility property will result in immediate disenrollment from the program. Do you agree to maintain property in the same condition it was provided? Yes No Cardinal Community House is a center that revolves around respect and courtesy regardless of race, gender, or sexual preferences. Do you agree to maintain a respectful and courteous environment for both clients and staff members? Yes No By signing below, I confirm that the information provided is accurate and truthful to the best of my knowledge. I understand that submitting this application does not guarantee admission to the shelter and that additional information or an intake interview may be required before I am admitted into the program.Applications are reviewed on Monday and Wednesday of each business week. If your time of application is submitted after Wednesday, it will be reviewed on the following Monday. All applicants will be provided a notice of approval or denial to the e-mail submitted on this application. Click here to accept Today's Date Signature: Submit