Please enable JavaScript in your browser to complete this form.Eligibility Criteria YA must be 18-24 and be homeless as defined by the Office of Homeless Youth (OHY). Yakima County ResidentDo you currently live in Yakima County?YesNoYour Contact InformationName *FirstLastLayoutDate of Birth *Phone *Contact Preferences *CallTextEmailIn-PersonPreferred Pronouns? *Email *Information About Your CircumstancesBackground Check Approval *YesNoA 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 TrainingUnable to WorkLack of ChildcareLoss of Job/UnemploymentEviction/Loss of HousingDischarged from hospital or other medical facilityDischarged from criminal/juvenile justice systemAged out of Foster CareMedical costsIllnessMental IllnessPhysical health/disabilityAlcohol/substance abuseDomestic ViolenceGuardian mental health/substance abuseFamily rejection/kicked outAbuse/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? *YesNoPlease 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.Name *FirstLastLayoutPhoneEmailPlease explain their relationship to you *Submit
