RAPID RE-HOUSING APPLICATION Rapid Re-Housing is a non-facility based housing program for the homeless. Services are only offered in our Clay & Clinton County offices in Missouri, and through affiliates in Johnson County, Kansas -- though rental units clients wish to lease may be located in adjoining counties. Please ask the case manager if the county you wish to live in is included in this program. The Rapid Re-Housing program provides case management and offers budgeting, financial counseling and financial assistance to move homeless clients into rental housing of their choosing within specific counties in Missouri & Kansas. A Youth Rapid Re-Housing program is available to clients age 24 and younger, including couples and youth with children of their own, through the Clay County, MO service office. Clients must be literally homeless to qualify (living on the streets, in a car, or other place not meant for human habitation, living in an emergency shelter, or fleeing domestic violence/assault). Step 1 of 11 9% GENERAL INFORMATIONPlease select your first choice of housing location.*If you are literally homeless, the Rapid Re-Housing program can help assist you to obtain rental housing through our service offices in Liberty and Cameron, MO. Case Managers may also be able to assist you in locating a rental unit located in one of the following counties in MO; Platte/Clay (select Clay County); Clinton, Ray, Caldwell, Daviess, Livingston (select Clinton County); DeKalb, Andrew, Buchanan (Select Northwest MO). Please contact the case manager if the county you wish to live in is not listed. The Youth Rapid Re-Housing program is limited to homeless youth & parenting youth age 24 & younger, focusing on Clay, Platte and Clinton Counties.Clay County, Missouri (Liberty, Gladstone, KC North, etc.)Clinton County, Missouri (Cameron & surrounding areas)Northwest MO / St. JosephYouth Rapid Re-Housing in Clay County, MissouriIf you would like to be considered for multiple Rapid Re-Housing service sites/programs, please select the sites below:Clay CountyClinton CountyNorthwest MOYouth Rapid Re-HousingApplicant Name*Please enter your first and last name: First Last Applicant Phone*Applicant EmailIs there a co-applicant (spouse/significant other)?YesNoCo-applicant*Please enter your co-applicant first and last name: First Last Co-Applicant Phone CURRENT LIVING ARRANGEMENTWhere are you living right now? (select one):*To be eligible for Rapid Re-Housing, you must be literally homeless. If you are not living in one of the places below, you are not eligible for the Rapid Re-Housing program.On the Street, in a Park, or other place not meant for human habitationIn a CarEmergency ShelterDomestic Violence ShelterTransitional Housing ProgramIn a Hotel that a Charity/Government paid for (no self-pay)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you been at this address/location?Have you been asked to leave your current living situation?YesNoIf Yes, How long can you stay there?24 hours1 Week2 Weeks1 MonthHave you ever participated in the Hillcrest Transitional or Rapid Re-Housing Program before?YesNoWho referred you to Hillcrest? HOUSEHOLD INFORMATIONList all who would be living in the apartment (including yourself):*(click the plus sign to add another person)NameRelationshipDate of BirthSS# (last four)Grade/SchoolRaceHispanic? Yes/No Have you or a member of your household (those living with you currently) been diagnosed with a disabling condition? Disabling conditions include physical, emotional & developmental disabilities, as well as chronic substance & alcohol abuse.Household MemberDisabling ConditionOther Information You Would Like to Share Anyone pregnant?YesNoWhen is the due date for the pregnancy? HOUSEHOLD EXPENSES List all Bills and Debts:*Please add an item for each of the following that apply: Past Rent, Cable, Electric, Gas, Telephone, Water, Student Loans, Medical, Clubs, Child Support, Repossessions, Bad Checks, Pawn Shop, Payday Loans, Tickets/Fines, Bankruptcy, Credit Cards, Storage, Childcare, Auto Payment, Auto Insurance, Title Loans, Cell/Pager, Other (click the plus sign to add another bill/debt)ItemAmount DueMonthly PaymentPast Due? (Yes or No) HOUSEHOLD INCOMEList CASH & NON-CASH Income currently received from a Job, Food Stamps, TANF, DFS (childcare/transportation assistance), SSI/SSDI, Medicare/Medicaid, SCHIP/Health Wave/HealthNet, etc. List EACH SOURCE separately, by Source & Monthly Amount Received. If child support is owed to you, please list monthly/total amount owed.(click the plus sign to add another income source)SourceMonthly Amount SOCIAL SERVICESPlease explain briefly the reasons for your current situation (Why you are Homeless or Losing your Housing). Please state WHERE you are staying, WHY you have to leave, and WHEN you must leave:*Do you currently have a Family Services/DSS case worker?YesNoCase Worker Name:Case Worker Phone Number:Name of Social Services Office: MEDICAL AND COUNSELING SERVICESDo you or any family members receive any medical or counseling services?YesNoIf Yes, please list the family members(click the plus sign to add another medication)Family MemberProblemMedication TRANSPORTATION INFORMATIONDrivers License NumberDriver's License State or State of IDPlease enter your driver's license state or the state of your state issued id?ID ExpirationPlease enter the expiration date of you driver's license or state issued ID.Do you have your own car?YesNoYear of Car*Make and Model of Car*Do you have car insurance?*YesNoCar Tag Number:*Are your Tags Current?*YesNoIs your car inpection current?*YesNoPlease add the state where your car's tag is registered.*Please list References/Emergency Contacts:(click the plus sign to add another contact)NameAddressPhoneRelationship PERSONAL HISTORYAgePlease enter a number from 1 to 100.SS# (last four digits)*Date of BirthLocation of BirthMarital StatusMarriedSingleDivorcedSeparatedWidowedDo you have previous marriages?YesNoPlease select highest education level you attainedSelect LevelGrades 1- 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Some CollegeCollege DegreePlease select the average grade you earned during your education.Select GradeABCDFPlease enter the name(s) of the school(s) and year graduated.(click the plus sign to add another school)Level (High School, GED, College, etc.)Name of SchoolYear Graduated Are you a military Veteran?YesNoIf yes, in which branch did you serve, and what years?Please list your job history (Last 5 Years):*(click the plus sign to add another job)Start Date/End DateCompany NamePay RateDutiesReason for Leaving/Current Job? Please list your family or emergency contacts(click the plus sign to add another family member)First & Last NameAddress (city, state)Phone Please list your Brothers and Sisters(click the plus sign to add another sibling)Brother/Sister NameAddress (city, state)Phone Do you smoke?YesNoHow much do you smoke per day?Do you use drugs or alcohol?YesNoHave you ever been in drug or alcohol rehabilitation?YesNoIf Yes, When?What is the name of abused substance?What rehabilitation facility did you attend?Are you an NA participant?YesNoHave you ever been arrested? (DWI, Bad Checks, Assault, ect.)YesNoIf Yes, What for?Did you receive a fine/sentence?YesNoHave you been a battered person?YesNoIf Yes, When were you battered? Date Format: MM slash DD slash YYYY Have you served any time in jail?YesNoIf Yes, How long were you in jail?Do you have any pending tickets? (speeding, parking, ect.)YesNoIf Yes, What were the pending tickets for?When is your court date?Are you on parole or probation at present?YesNoIf Yes, How long?Parole/Probation Officer:Parole/Probaton Officer Phone NumberIs there a warrant(s) out for your arrest at present?YesNoIf Yes, Reason for Warrant(s) CO-APPLICANT PERSONAL HISTORYAge:Please enter a number from 1 to 100.SS# (Last for digits)Date of BirthLocation of BirthMarital StatusMarriedSingleDivorcedSeparatedWidowedHas co-applicant been previously married?YesNoPlease select the highest level of education co-applicant attainedSelect LevelGrades 1- 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Some CollegeCollege DegreePlease select the average grade co-applicant earned during their educationSelect GradeABCDFPlease enter the name(s) of the school(s) and year graduated.(click the plus sign to add another school)Level (High School, GED, College, etc.)Name of SchoolYear Graduated Are you a military Veteran?YesNoIf yes, in which branch did you serve, and what years?Please list co-applicant job history (Last 5 years)(click the plus sign to add another job)YearCompany NamePay RateDutiesReason for Leaving Please list co-applicant family members(click the plus sign to add another family member)Parents NamesAddress (city, state)Phone Please list co-applicant Brothers and Sisters(click the plus sign to add another sibling)Brother/Sister NameAddress (city, state)Phone Does the co-applicant smoke?YesNoHow much does the co-applicant smoke per dayDoes the co-applicant use drugs or alcohol?YesNoHas the co-applicant ever been to drug or alcohol rehabilitation?YesNoIf Yes, When?:Please enter the name of the abused substance:Please enter the name of the facility the Co-Applicant attended during rehabilitation.Is the co-applicant an AA participant?YesNoIs the co-applicant a NA participant?YesNoHas the co-applicant ever been arrested? (DWI, bad checks, assault, ect.)?YesNoIf Yes, What for?Did the co-applicant receive a fine/sentence?YesNoHas the co-applicant been a battered person?YesNoIf Yes, When? Date Format: MM slash DD slash YYYY Has the co-applicant served any jail time?yesnoIf Yes, How long?Does the co-applicant have any pending tickets? (speeding, parking, ect.)YesNoIf Yes, What for?When is the co-applicant's court date?Is the co-applicant on parole or probation at present?YesNoIf Yes, who is the co-applicant's parole/probation officerWhat is the co-applicant's parole/probaton officer's phone numberIs there a warrant(s) out for the co-applicant's arrest at present?YesNoPlease describe the reason for the co-applicant warrant(s)? By submitting this application, I agree that the preceding information is true and accurate to the best of my knowledge. The following rules of conduct shall be in effect while clients participate in the Hillcrest Rapid Re-Housing Program. Violation of any rule will, at the discretion of the Board or the Staff, be cause for immediate dismissal from the program. Hillcrest Services: 1. No illegal activity of any kind will be permitted at Hillcrest properties/service sites. 2. All adults in the program are expected to find and/or maintain income which will sustain permanent housing – including employment, SSI, SSDI or a combination of sustainable income sources. 3. All adults must attend scheduled meetings and appointments. Rental Lease Terms: 4. Any new lease you enter into is between you and the landlord; Hillcrest is not a party to your lease agreement and is not liable for any fees you may incur outside of the unrelated Hillcrest/Landlord Agreement. 5. Follow the rules of the lease: a. No fighting of any kind will be tolerated. b. No illegal activity including the use of illegal substances will be permitted. c. Follow lease policies regarding pets, smoking, overnight guests, trash etc. 6. Rental unit must be kept clean and free of clutter. I have read and understand if I violate any one of these rules I may be dismissed from the Hillcrest Rapid Re-Housing Program. I also understand that I may be asked to leave the program at any time for any other reason. I agree not to hold Hillcrest and/or any other persons associated with the program responsible/liable, singly or collectively, from injury, misadventure, harm, loss, inconvenience or damage sustained as a result from participating in this program. I give permission for information to be released about myself and my children by or to any doctor, social worker, counselor, employer, current/former/future landlord, current/former/future vendor (utility companies, law firms, collection agencies, etc.), shelter or agency as deemed necessary by Hillcrest. I give permission for information about myself and my children to be entered into the local homeless management information system, including but not limited to MAAC, CaseWorthy, &/or ICA-ServicePoint. I agree my acceptance into the Hillcrest Rapid Re-Housing Program is not a landlord agreement or guarantee of fund assistance, but an application to receive supportive housing services and possible financial assistance provided by Hillcrest.