Young Adult Emergency Home Application

Eligibility Criteria

YA must be 18-24 and be homeless as defined by the Office of Homeless Youth (OHY).

Yakima County Resident

Do you currently live in Yakima County?

Your Contact Information

Name *

First

Last

Date of Birth *

Phone *

Contact Preferences *

Call
Text
Email
In-Person

Preferred Pronouns? *

Email *

Information About Your Circumstances

Background Check Approval *

A background check will be done to ensure you do not have any pending legal issues, is that ok? (this is to help you get legal services if needed)

Circumstances that lead to housing status (check all that apply): *

Lack of Job Training
Unable to Work
Lack of Childcare
Loss of Job/Unemployment
Eviction/Loss of Housing
Discharged from hospital or other medical facility
Discharged from criminal/juvenile justice system
Aged out of Foster Care
Medical costs
Illness
Mental Illness
Physical health/disability
Alcohol/substance abuse
Domestic Violence
Guardian mental health/substance abuse
Family rejection/kicked out
Abuse/Neglect

What are your plans to get into stable housing? *

What barriers do you think you will face to get into stable housing? *

Americans with Disabilities Act

It is your responsibility to make your needs for accommodations known to Rod’s House. Indicate any disabilities that might affect access to the bedroom, bathroom, or common areas.

Do you have a disability? *

Please list any medical conditions to be considered when making room assignments, e.g. heart condition, diabetes, severe allergies, etc.

Emergency Contact

Please list a contact that can be reached in case of emergency.

Name *

First

Last

Phone

Please explain their relationship to you *

PUBLIC RESOURCES

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CONTACT

32 N. 3rd St., Ste 235
Yakima, WA 98901

office@rodshouse.org

(509)-895-2665

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