#HELP Registration Form
The Help Project - Help Birmingham
We're here to #HELP
This form is a quick and conevenient information intake
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
Divorced
Married
Single
Widowed
Employment status
*
Disabled
Full Time
Part Time
Unemployed
Retired
If employed, how much is the monthly income? ($)
Please list the name of your employer(s)
*
How much is the monthly rent? ($)
How many are you in your household?
How many of them are children?
How many adults?
How many seniors?
Please list the details of your household below:
Signature
Clear
Date Signed
-
Month
-
Day
Year
Date
Housing Status
Are you able to pay your current rent/mortgage in full and on-time most months?
*
Yes
No
Are you in danger of eviction due to late or missing payments?
*
Yes
No
Are you currently enrolled in a rental assistance program?
*
Yes
No
If yes, what program?
Are you currently enrolled in the Section 8 program?
*
Yes
No
Is your current housing classified as "affordable housing"?
Yes
No
How long have you lived at your current location?
*
How many times have you moved in the last ten years?
*
Why did you move from your last residence?
*
COVID-19 QUESTIONS & SCREENING
Have you tested positive for COVID-19?
*
Yes
No
If so, When
*
Have you retested negative since then?
*
Yes
No
If so, When
*
Are you currently experiencing any of the following symptoms?
New or worsening cough
New shortness of breath
Muscle or body aches
Nausea or vomiting
Difficulty breathing
Other
Has COVID-19 affected your income over the past 60 days?
*
Yes
No
Has COVID-19 affected your income over the past 60 days?
*
Yes
No
If yes, please explain:
*
Homeless Status
Have you ever been homeless?
*
Yes
No
Are you currently homeless?
*
Yes
No
If so, when and for how long?
*
Needs Assessment
IN YOUR OPINIION, what are 3 things/problems that are threatening your current housing situation or putting you the position of needing help with your rent?
*
Do you own a car or have viable transportation?
*
Yes
No
Is the car in need of maintenance or repair?
*
Yes
No
In your own words, please briefly tell us what your situation is.
*
Submit
Should be Empty: