Eligibility Requirements (PLEASE READ): Must be a resident of Bath, Menifee, Montgomery, Morgan or Rowan County for a minimum of 30 days and provide proof of residency. Some examples of proof of residency may include DCBS food benefits case, current bill, paycheck stub with address or photo id or drivers license. Also must have some form of a photo id prior to being admitted to shelter.

Since the safety of the men, women and children staying at Gateway House is a top priority, criminal background checks which reveal violent offenses, sexual offenses or any other offenses which may affect the safety and well-being of GHC residents and staff will be carefully evaluated to determine eligibility.

* all fields are required

Last Name*
First Name:*
Middle Name*
Date Of Birth:*
Age: *
Social Security Number:*
Marital Status:*
Address:*
How Long At This Address?*
Telephone #:*
-
Gender:*
Weight:*
Why are you Currently Homeless?*
Previous Address:*
How Long At This Address?:*
Why Did You Leave?*
Referral Source:*
Name:
Sex:
Relationship to Applicant
Date Of Birth:
SS #:
Name 2:
Sex 2:
Relationship to Applicant 2
Date Of Birth 2:
SS # 2:
Name 3:
Sex 3:
Relationship to Applicant 3
Date Of Birth 3:
SS # 3:
Name 4:
Sex 4:
Relationship to Applicant 4
Date Of Birth 4:
SS # 4:

(Please answer for everyone applying for shelter)

Have you ever been a resident of Gateway House?*
Do you require special accommodations to climb stairs?*
Has anyone applying ever been to jail anywhere at any time?*
If Yes, please describe
If so, Where?
If so, When?
Does anyone applying have any pending charges?*
Is anyone applying on parole or currently on probation?*
Does anyone applying currently have an Emergency Protective Order (EPO) or Domestic Violence Order (DVO) in Place?*
If Yes, Please Explain:

NON-DISCRIMINATION: Gateway Homeless Coalition, Inc. (GHC) does not discriminate against any person in the provision of services or in any other manner on the grounds of race, color, ethnicity, creed, religion, sex, national origin, sexual orientation, gender identity, citizenship, marital status, familial status, ancestry, age, disability or veteran status. If you feel like you have been discriminated against by GHC, please contact the Executive Director immediately or the local title VI Coordinator at 606.784.2668.

CONFLICT OF INTEREST: I (we) certify that I (We) or any member of my family, are not an employee of GHC, not a member of GHC board of directors, not related to an employee of GHC and not related to a member of the GHC board of directors. If such relationship exist, please notify staff.

CONFIDENTIALITY/PERMISSION STATEMENT: By signing below, I (we) hereby state that all of the information on this application is true, correct and complete to the best of my (our) knowledge. I (we) also give GHC the right to check my (our) criminal background information. I hereby agree to assure the confidentiality of other program participants and applicants at GHC. I (we) understand and agree that my application and file may be reviewed by GHC funders, including but not limited to the Kentucky Housing Corporation, Homeless and Housing Coalition of Kentucky, Department of Housing and Urban Development and any other funders who have a legitimate interest.

Emergency Contact Name:*
Emergency Contact Telephone:*
Emergency Contact Relationship:*
Applicant's Electronic Signature:*
Please Check The "I'm not a robot checkbox"
Spouse's or Co-Applicant's Electronic Signature (if applicable):