Please complete this form to be added to our waiting list

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Head of Household Information

First Name

MI

Last Name

Phone number

Make sure this is correct.
We cannot reach you without a phone number.
We cannot call or message international numbers.

E-mail address

What is your date of birth?

DD/MM/YYYY

How many children are with you?

17 years old and younger

What are your children's ages and genders?

5B, 2G = Five-year-old boy, two-year-old girl

Any other adults? Partners, spouses, parents?

YesNoAnyone over 18-years-old is considered an adult

2nd Adult Info

First Name

MI

Last Name

What is this person's relationship to you?

Grandmother, spouse, son, etc

What is their date of birth?

Any other adults?

YesNo

3rd Adult Info

First Name

MI

Last Name

What is this person's relationship to you?

What is their date of birth?

Any other adults?

YesNo

4th Adult Info

First Name

MI

Last Name

What is this person's relationship to you?

What is their date of birth?

Your Situation

Please tell us in as much detail as possible.
The more information you give us, the better.

How did you become homeless?

What city did you live in before becoming homeless?

What was your zip code before becoming homeless?

What county did you live in before becoming homeless?

Where are you currently sleeping?

Car? Streets? Couch surfing? With family?

In what city are you currently sleeping in?

Anything else you would like us to know?

How did you hear about us?

Do you or anyone in your family have any of the
symptoms below within the last three days?

No, we do not have any symptomsYes, at least one of the symptoms below

ATTENTION:
IMPORTANT WAITLIST
INFORMATION BELOW

If we have an opening, we will call a family that is checking in with us.

You will not be called if you are not checking in.

If you need shelter,
please read and follow
the instructions below carefully:

TAKE A SCREENSHOT OF THESE INSTRUCTIONS:

How to check into our wait list:
Send a text daily with your full name to
Stephanie at (408) 516-5117
From 10 AM - 11 AM
Monday - Friday

or

Call (408) 926-8885
From 10 AM - 11 AM
Monday - Friday

We will reach out to you when we
have a room for your family.

But you need to check in with us daily.

By typing your initials in the box below, you are confirming you understand our wait list check in process.

Do we have your permission to share your contact information
with other family agencies in Santa Clara County that might have shelter or resources for your family?

Yes, you can share my information.No, do not share my information.

Organizations who are also committed to helping families

Resources on the next page

Please complete this form to be added to our waiting list

ATTENTION: IMPORTANT WAITLIST INFORMATION BELOW

If you need shelter, please read and followthe instructions below carefully:TAKE A SCREENSHOT OF THESE INSTRUCTIONS:

ATTENTION:
IMPORTANT WAITLIST
INFORMATION BELOW

If you need shelter,
please read and follow
the instructions below carefully:

TAKE A SCREENSHOT OF THESE INSTRUCTIONS: