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Mary & Martha House
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Apply for Shelter
Intake Form
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Contact Information
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Step
1
of 10
Transformation Starts Here.
Please fill out the form below to begin. All information is confidential.
What is your name?
*
First
Middle
Last
What is your email address?
*
What is the best phone number to reach you?
*
What is your date of birth?
*
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Do you need a Spanish interpreter?
*
Yes
No
Next
Are you Pregnant?
*
Yes
No
Not Sure
Do you have children?
*
Yes
No
How many children do you have?
*
Child 1
Child 1 Gender
*
Male
Female
Child 1 Age
*
Child 2
Child 2 Gender
*
Male
Female
Child 2 Age
*
Child 3
Child 3 Gender
*
Male
Female
Child 3 Age
*
Child 4
Child 4 Gender
*
Male
Female
Child 4 Age
*
Are your children in school/daycare?
*
Yes
No
How do you pay for school/daycare?
*
Previous
Next
Tell us about your current living situation
Are you homeless?
*
Yes
No
Briefly explain your situation:
*
Are you in Hillsborough county?
*
Yes
No
What county?
*
For how long?
*
Where did you sleep last night?
*
Have you ever lived in a shelter?
*
Yes
No
Where?
City/County/State
*
Length of stay?
*
Previous
Next
Are you currently employed?
*
Yes
No
Where are you employed?
*
How long have you been employed?
*
Who is your previous employer?
*
How long were you employed?
*
Previous
Next
Highest level of education
*
Some High School
High School Graduate or Equivalent
Occupational, technical or vocational program
Some College
College Degree
What is your monthly income?
*
SSI, SSDI
Child Support
Food Stamps
WIC
*
Yes
No
Other Income?
*
Yes
No
What and how much?
*
Previous
Next
Do you have a valid drivers license or Florida identification?
*
Yes
No
Do you own a car?
*
Yes
No
Is your car registered?
*
Yes
No
Is your car insured?
*
Yes
No
Previous
Next
Identifying Documents
Do you have your birth certificate?
*
Yes
No
Does Child 1 have a birth certificate?
*
Yes
No
Does Child 2 have a birth certificate?
*
Yes
No
Does Child 3 have a birth certificate?
*
Yes
No
Does Child 4 have a birth certificate?
*
Yes
No
Do you have a social security card?
*
Yes
No
Does Child 1 have a social security card?
*
Yes
No
Does Child 2 have a social security card?
*
Yes
No
Does Child 3 have a social security card?
*
Yes
No
Does Child 4 have a social security card?
*
Yes
No
Previous
Next
Have you ever been arrested?
*
Yes
No
What County and State?
*
Charges
*
Convicted?
*
Yes
No
If charges were dropped, do you have paperwork?
*
Yes
No
Are you working with an attorney for this or any other situation?
*
Yes
No
Previous
Next
Have you had an eviction?
*
Yes
No
Please explain:
*
Can you pass a drug test today?
*
Yes
No
Are you taking any medications?
*
Yes
No
Please explain:
*
Are you a victim of domestic violence?
*
Yes
No
For how long?
*
Is your abuser actively seeking you?
*
Yes
No
Is there a case against your abuser?
*
Yes
No
Previous
Next
Please answer the following important Covid-19 questions honestly.
Have you been around anyone who has any of the following symptoms in the last 14 days: Sore throat, cough, chills, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100°F?
*
Yes
No
Have you or anyone in your household visited or receive treatment at a hospital, nursing home, long-term care, or other healthcare facility in the past 30 days?
*
Yes
No
Have you or anyone in your household traveled in/out of the US in the past 21 days?
*
Yes
No
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
*
Yes
No
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?
*
Yes
No
Signature
Enter your full name below:
All information is confidential.
Previous
Submit
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Newsletter
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Sponsor an Event
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