Almost Home Application

Foundations to Success Program*

I am 16-21 years old and need housing in the St. Louis area. I want to apply today.

Name*

First Name

Last Name

Current Cell Phone Number*

Alternate Phone Number

Date of Birth*

Age*

Email

Current Street Address

Current City/Town

Current State

Current Zip Code

Current Living Situation*

Ethnicity

African American Caucasian Asian Hispanic Bi-Racial Other

Where do you currently live?

City County Other

How many children do you have?*

Are you currently pregnant?*

Yes No

If you are pregnant, what is your due date?*

How did you hear about Almost Home?*

Friend Family Member Former Member Another Agency Website Other

If you selected other, please tell us how you heard about Almost Home?

Do you have a high school diploma or GED?*

Yes No

What School?

What are you doing currently?

Enrolled in school or a program Working Not currently working or enrolled in school/program

What school or program?

Where are you working?

Do you have any income currently?*

Yes No