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Housing Stability:

Employment History:

Sources of Income:

Education History:

Children:

Medical History:

Mental Health History:

Legal History:

Emergency Contact:

Emergency Contact:

I certify that the information provided in this application is true and accurate to the best of my knowledge.

I understand that my acceptance to The Salvation Army's Gettin' Ahead in a Just-Getting-By World is dependent upon my needing such assistance and is dependent upon any eligibility guidelines that are established by The Salvation Army or its funding entities.

I certify that I am able to and will fully participate in the activities of the program.

I understand that, if accepted for entry, my decision to enter The Salvation Army's Gettin' Ahead in a Just­-Getting-By World is voluntary. I agree for myself, my heirs and assigns, that should any accident occur to myself that results in personal injury or death, or should any loss or damage occur to my personal property, during my residence in this facility or any activities associated with my participation in this prog, I hold The Salvation Army, free and harmless from any and all liabilities in connection therewith.