#HELP Registration Form

#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? *
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. *
Should be Empty:

#HELP Registration Form

We're here to #HELP

Housing Status

Homeless Status

Needs Assessment