Registration for Refuge House LLC

** PLEASE DO NOT LEAVE PERSONAL INFO ON THIS FORM SUCH AS SOCIAL SECURITY NUMBER OR PERSONAL IDENTIFIERS **

Date

Month

Day

Year

First name

Last name

Phone

Birthday

Month

Day

Year

Are you currently Homeless ?

Do you receive Government Assistance ? If so, How Much?

How soon are you needing housing?

Are you okay with Sharing a room with someone else?

Are you able to follow rules of the house ?

Do you possess a valid Debit Card ?

Please list the organization/case manager or Individual who Referred you to Refuge House LLC

This form is to register with Refuge House . Please limit to one registration per individual. WE ONLY OFFER SHARED HOUSING. We are currently operating off of a waitlist. When we reach your name we will reach out with intake and application forms to continue onboarding and possible move ins. Thank you for registering with refuge house LLC.