THE PATHWAYS CENTER APPLICATION

DO NOT COMPLETE THIS AREA. FOR OFFICE USE ONLY
Date applied: __________________	Case Name: ______________	Room assigned: __________
Date admitted: _________________		Case Number: __________

List all family members, beginning with adults, applying to stay at Pathways Center.

Name	Date of Birth	Age	Race	Sex	Marital Status	SS#	School Grade

Has any family member ever been in the military? o No o Yes If yes, who________________

REASON SEEKING ADMISSION
o (a) Burned out of home	Explain_______________________________________
o (b) Evicted	______________________________________________
o (c) Overcrowded housing	______________________________________________
o (d) No place to live/motel	______________________________________________
o (e) Can’t stay with family/not on the lease	______________________________________________
o (f) Domestic violence	______________________________________________
o (g) Domestic conflicts – Non-violent	______________________________________________
o (h) Relocation	______________________________________________
o (i) Other	______________________________________________

RESOURCES
$________	Work First/TANF
$________	Food Stamps
$________	Social Security (SSA and/or SSI)
$________	Wages per hour __________Number of hours worked per week
	Employer_____________________________
$________	Wages per hour __________Number of hours worked per week
	Employer_____________________________
$________	Child Support: Per o Month o Week o Other______________
$________	Other List _________________________________________

DEBTS/PAST DUE BILLS/MONTHLY BILLS
$________	Duke Power	$________	Piedmont Natural Gas
$________	Water	$________	Greensboro Housing Authority
$________	Landlords	$________	Insurance
$________	Storage	$________	Car
$________	Cell Phone	$________	Other_____________________________

HOUSING:
Have you ever stayed at Pathways?		o Yes o No
Have you applied for public housing with Greensboro Housing Authority?		o Yes o No
Have you applied for Section 8 housing?		o Yes o No
If yes, when? _________________________________________
Have you ever stayed in public housing or Section 8 housing?		o Yes o No
If yes, where? _______________________________	When? _____________
Why did you leave? ________________________________________________________________________________
Have you applied for any other housing?		o Yes o No
If yes, where? _________________________________________________________________________________

PERSONAL/FAMILY INFORMATION:
Do you have custody of your children?	o Yes o No
If not, who does have custody? _________________________________________________________
Do you have a Social Worker, Work First worker, a Child Protective Services worker, or a Foster Care worker with the Department of Social Services?	o Yes o No
If so, what is her/his name? ____________________________________________________________
Are any other agencies assisting you or your children?	o Yes o No
If so, list the agency and the worker. ______________________________________________________
What is your cell number? ____________________________________

Contact Person: _______________________Phone: _____________ Relationship:____________________

AUTHORIZATION TO REQUEST AND /OR RELEASE INFORMATION

I hereby authorize Greensboro Urban Ministry and its staff to request and/or release any and all information regarding my family’s employment history, financial affairs, medical history, housing history, applications for assistance, family and personal relationships, and such information as may be needed.

Date:	_________________________	*	______________________________________
			Signature
		*	______________________________________
			Signature

*Application must be signed by all adults applying for admission.

Complete and mail to:

The Pathways Center
3517 N. Church St., Greensboro, NC 27405

Or fax to: 336-271-5926

After sending, you must call Mark Sumerford or Cathy Osborne: 336-271-5988.