Are you in need of shelter? Please complete the Shelter Application below. We receive a high volume of applicants and have very few openings in our shelter. If you have any questions, please call our office: (978) 922-0787 EMERGENCY SHELTER APPLICATION LEAD APPLICANT INFORMATION (Head of Household) Please complete entirely. Due to the high volume of applications and our shelter's size, not every applicant will receive a call-back. Name (Head of Household) * First Last Phone Number * Email Address Last Permanent Address Address Line 1 Address Line 2 City * State * Zip Code Country Last place you've lived for longer than 6 months and/or where you last paid rent. Gender Identity * i.e. Male, Female, Non-Binary, Other, N/A... Date of Birth * Racial or Ethnic Identity * Black/African-American Hispanic/Latinx Asian American Indian/Alaska Native Pacific Islander White/Caucasian Other Prefer not to answer Please select all that apply. Income/Benefits (Check all that apply) * Employment SSI/SSDI Unemployment Benefits Child Support TANF/TAFDC Retirement SNAP (Food Stamps) Other None Approximate Monthly Income for Lead Applicant and Children * Please include your income and any income received from children. Employment Status * Currently employed Not employed as of recently (within this last year) Have not been employed for over a year Have never been employed Please describe your history of employment (types of jobs, reason for unemployment): HOUSING SITUATION Please tell us more about your current housing situation and needs. Current Housing Situation * — Select — Renting Hotel/Motel Friends/Family Vehicle/Outdoors Emergency Shelter Other What best describes the reason your family is experiencing homelessness, or is at risk of homelessness? * Eviction/foreclosure due to non-payment Domestic Violence Habitat unsuitable for living (i.e. mold, lead, asbestos) No longer able to live with friends/family Fire/Flood/Natural Disaster Other Please provide a bit more detail about the events that led to your family’s homelessness or risk of homelessness… * What town is your family from? * Are you willing to relocate for a housing opportunity? (If yes or no, please elaborate) * Including yourself, how many members of your household need shelter? * SECOND ADULT INFORMATION Please list information of second adult also seeking assistance... Is there a second adult in the household? * Yes No Full Name First Last Phone Number Email Address Gender Identity i.e. Male, Female, Non-Binary, Transgender, N/A... Date of Birth Racial or Ethnic Identity Black/African-American Hispanic/Latinx Asian American Indian/Alaska Native Pacific Islander White/Caucasian Other Prefer not to answer Please select all that apply. Is the second adult a parent or legal guardian of any of the children listed? Yes No Other Income/Benefits (Check all that apply) Employment SSI/SSDI Unemployment Benefits Child Support TANF/TAFDC Retirement SNAP (Food Stamps) Other None Employment Status Currently employed Not employed as of recently (within this last year) Has not been employed for over a year Has never been employed Please describe your history of employment (types of jobs, reason for unemployment): Their Approximate Monthly Income CHILDREN Please provide information regarding your children... List Children (Age, Gender Identity, Initials): * Initials, Age, Gender Identity (i.e. Male, Female, Non-Binary...) Are any of the children in school or daycare? * Yes No Other OTHER HOUSEHOLD INFORMATION Please provide some additional information to help us provide the best assistance. Total Household Monthly Income * Please list the total amount of your household's income from all sources. Do you have a vehicle? * Yes No Do you or any adult member of your household have a criminal history? * Arrest Conviction Probation/Parole Pending Charges Other - Not listed No Criminal History Please note that our shelter is a low-barrier program. Having a criminal history will not prevent admission to the program. However, failure to answer this question and omission of details could lead to future discharge from the program. Does any member of your household have a history with substance use disorder? * Yes No Other If yes, how many months have they been sober? How many months of sobriety? (If less than one month, just put "1") Do you have any pets? * Yes No If yes, please specify: i.e. "One dog, two cats." How did you hear about Family Promise North Shore Boston? 211 Department of Transitional Assistance (DTA) Google Search Other Social Service Agency Social Security Administration Social Media Church, Temple, or Faith-Based Organization Friend/Family Other Is there any other critical information that you would like us to know about your family and your current situation?
