Service Number:

Dates of Service:

Did you serve in a war zone?

Yes No

Ethnicity: White Black American Indian Asian Other

Birthdate:

Birthplace :

Message Address:

Message Phone:

How Long Have You Been Homeless?

Have you attended Stand A Down before?

Yes No

Where?

When?

Height:

Weight:

Do you Exercise? :

Hair Color:

Eye Color :

Gender :

Highest Grade Completed:

Usual Occupation:

Last Wage:

Current Medical Problems ?

Date Last Employed?

Emotional Problems?

Yes No

Do You Need Help With Outstanding Warrants?

Yes No

Describe the nature of your Legal problems:

Other Problems, Please list them:

Do you have a Child Support case being administered by Shasta County D.C.S.S. Yes No

Will any dependent family member be attending with you Yes No .

How Many ? 1 2 3 4 5 6 7 8 9 10 more