RRH Old App

GENERAL INFORMATION
Please 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. Joseph
- Youth Rapid Re-Housing in Clay County, Missouri
If you would like to be considered for multiple Rapid Re-Housing service sites/programs, please select the sites below:
Applicant Name*
Please enter your first and last name:
First Last
Applicant Phone*
Applicant Email
Is there a co-applicant (spouse/significant other)?
- Yes
- No
Co-applicant*
Please enter your co-applicant first and last name:
First Last
Co-Applicant Phone

CURRENT LIVING ARRANGEMENT
Where 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.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long have you been at this address/location?
Have you been asked to leave your current living situation?
- Yes
- No
If Yes, How long can you stay there?
Have you ever participated in the Hillcrest Transitional or Rapid Re-Housing Program before?
- Yes
- No
Who referred you to Hillcrest?

HOUSEHOLD INFORMATION
List all who would be living in the apartment (including yourself):*
(click the plus sign to add another person)
Name Relationship Date of Birth SS# (last four) Grade/School Race Hispanic? 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 Member Disabling Condition Other Information You Would Like to Share
Anyone pregnant?
- Yes
- No
When 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)
Item Amount Due Monthly Payment Past Due? (Yes or No)

HOUSEHOLD INCOME
List 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)
Source Monthly Amount

SOCIAL SERVICES
Please 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?
- Yes
- No
Case Worker Name:
Case Worker Phone Number:
Name of Social Services Office:

MEDICAL AND COUNSELING SERVICES
Do you or any family members receive any medical or counseling services?
- Yes
- No
If Yes, please list the family members
(click the plus sign to add another medication)
Family Member Problem Medication

TRANSPORTATION INFORMATION
Drivers License Number
Driver's License State or State of ID
Please enter your driver's license state or the state of your state issued id?
ID Expiration
Please enter the expiration date of you driver's license or state issued ID.
Do you have your own car?
- Yes
- No
Year of Car*
Make and Model of Car*
Do you have car insurance?*
- Yes
- No
Car Tag Number:*
Are your Tags Current?*
- Yes
- No
Is your car inpection current?*
- Yes
- No
Please add the state where your car's tag is registered.*
Please list References/Emergency Contacts:
(click the plus sign to add another contact)
Name Address Phone Relationship

PERSONAL HISTORY
Age
Please enter a number from 1 to 100.
SS# (last four digits)*
Date of Birth
Location of Birth
Marital Status
- Married
- Single
- Divorced
- Separated
- Widowed
Do you have previous marriages?
- Yes
- No
Please select highest education level you attained
Please select the average grade you earned during your education.
Please 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 School Year Graduated
Are you a military Veteran?
If 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 Date Company Name Pay Rate Duties Reason for Leaving/Current Job?
Please list your family or emergency contacts
(click the plus sign to add another family member)
First & Last Name Address (city, state) Phone
Please list your Brothers and Sisters
(click the plus sign to add another sibling)
Brother/Sister Name Address (city, state) Phone
Do you smoke?
- Yes
- No
How much do you smoke per day?
Do you use drugs or alcohol?
- Yes
- No
Have you ever been in drug or alcohol rehabilitation?
- Yes
- No
If Yes, When?
What is the name of abused substance?
What rehabilitation facility did you attend?
Are you an NA participant?
- Yes
- No
Have you ever been arrested? (DWI, Bad Checks, Assault, ect.)
- Yes
- No
If Yes, What for?
Did you receive a fine/sentence?
- Yes
- No
Have you been a battered person?
- Yes
- No
If Yes, When were you battered?
Date Format: MM slash DD slash YYYY
Have you served any time in jail?
- Yes
- No
If Yes, How long were you in jail?
Do you have any pending tickets? (speeding, parking, ect.)
- Yes
- No
If Yes, What were the pending tickets for?
When is your court date?
Are you on parole or probation at present?
- Yes
- No
If Yes, How long?
Parole/Probation Officer:
Parole/Probaton Officer Phone Number
Is there a warrant(s) out for your arrest at present?
- Yes
- No
If Yes, Reason for Warrant(s)

CO-APPLICANT PERSONAL HISTORY
Age:
Please enter a number from 1 to 100.
SS# (Last for digits)
Date of Birth
Location of Birth
Marital Status
- Married
- Single
- Divorced
- Separated
- Widowed
Has co-applicant been previously married?
- Yes
- No
Please select the highest level of education co-applicant attained
Please select the average grade co-applicant earned during their education
Please 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 School Year Graduated
Are you a military Veteran?
If 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)
Year Company Name Pay Rate Duties Reason for Leaving
Please list co-applicant family members
(click the plus sign to add another family member)
Parents Names Address (city, state) Phone
Please list co-applicant Brothers and Sisters
(click the plus sign to add another sibling)
Brother/Sister Name Address (city, state) Phone
Does the co-applicant smoke?
- Yes
- No
How much does the co-applicant smoke per day
Does the co-applicant use drugs or alcohol?
- Yes
- No
Has the co-applicant ever been to drug or alcohol rehabilitation?
- Yes
- No
If 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?
- Yes
- No
Is the co-applicant a NA participant?
- Yes
- No
Has the co-applicant ever been arrested? (DWI, bad checks, assault, ect.)?
- Yes
- No
If Yes, What for?
Did the co-applicant receive a fine/sentence?
- Yes
- No
Has the co-applicant been a battered person?
- Yes
- No
If Yes, When?
Date Format: MM slash DD slash YYYY
Has the co-applicant served any jail time?
- yes
- no
If Yes, How long?
Does the co-applicant have any pending tickets? (speeding, parking, ect.)
- Yes
- No
If Yes, What for?
When is the co-applicant's court date?
Is the co-applicant on parole or probation at present?
- Yes
- No
If Yes, who is the co-applicant's parole/probation officer
What is the co-applicant's parole/probaton officer's phone number
Is there a warrant(s) out for the co-applicant's arrest at present?
- Yes
- No
Please 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.

RAPID RE-HOUSING APPLICATION

Step 1 of 11

GENERAL INFORMATION

CURRENT LIVING ARRANGEMENT

HOUSEHOLD INFORMATION

HOUSEHOLD EXPENSES

HOUSEHOLD INCOME

SOCIAL SERVICES

MEDICAL AND COUNSELING SERVICES

TRANSPORTATION INFORMATION

PERSONAL HISTORY

CO-APPLICANT PERSONAL HISTORY

Name	Relationship	Date of Birth	SS# (last four)	Grade/School	Race	Hispanic? Yes/No

Household Member	Disabling Condition	Other Information You Would Like to Share

Level (High School, GED, College, etc.)	Name of School	Year Graduated

Start Date/End Date	Company Name	Pay Rate	Duties	Reason for Leaving/Current Job?

Item	Amount Due	Monthly Payment	Past Due? (Yes or No)

Source	Monthly Amount

Family Member	Problem	Medication

Name	Address	Phone	Relationship