The Jeremiah 2911 House Intake Application The 2911 House Intake Application Name * Name First Name First Name Last Name Last Name Email * Confirm Email * Phone * Text Capable * Yes No Date of Birth * Are you a US citizen? * Yes No If not a citizen what is your legal status? Are you homeless? * Yes No If no, who are you currently living with? NC County of Residence * Current Street Address * Current City Address * Current State Address * Current Zip Address * Are you pregnant? * Yes No If yes, when is your due date? Number of children in your custody. * 0 1 2 3 How did you hear about the Jeremiah Project or the 2911 House? * Age of Child 1 Gender of Child 1 Male Female Age of Child 2 Gender of Child 2 Male Female Age of Child 3 Gender of Child 3 Male Female Age of Child 4 Gender of Child 4 Male Female Why did you contact us? How can we help you? * Income Situation * I am currently working full time I am currently working part time I am actively seeking employment I am receiving Disability Funds Please provide us with any additional information you think would help us understand your situation. Background Do you have a criminal record? * Yes No Can you pass a drug screening? * Yes No Are you in an active domestic violence situation? * Yes No Submit If you are human, leave this field blank.
