Young Adult Emergency Home ApplicationΔ Eligibility CriteriaYA must be 18-24.YA must be homeless as defined by the Office of Homeless Youth (OHY).First NameLast NameDate of BirthWhat are your preferred pronouns?Phone NumberEmailContact Preference Call Text EmailA background check will be done to make sure you do not have any pending legal issues, is that ok? (this is to help you get legal services if needed) Yes NoCircumstances that lead to housing status (check all that apply) Lack of Job Training Unable to Work Lack of Childcare Loss/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/NeglectWhat are your plans to get into stable housing?What barriers do you think you will face to get into stable housing?Americans with Disabilities ActIt 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? Yes NoDo you have a disability that affects your mobility? Yes NoIf yes, please explainDo you have a disability that affects your vision? Yes NoIf yes, please explainDo you have a disability that requires a wheelchair? Yes NoIf yes, please explainPlease list any medical conditions to be considered when making room assignments, e.g. heart condition, diabetes, severe allergies, etc. Emergency ContactPlease list a contact that can be reached in case of emergency.First NameLast NamePhone NumberEmailPlease explain their relationship to youSubmit Form
