Referrals

Thank you for partnering with us to serve low-income single mothers in Chatham County. If you are referring a single mother in need of assistance, please complete the application below. Be sure to include a list of specific needs in the box provided. We will review the application and schedule an intake interview within the next 2-4 weeks.

Shelter From the Rain Inc. Referral Form

* Indicates required field

Referral Source Organization *

Referral Code *

Referral Contact Person *

Family Information

Mother's Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Birthdate (Please include the year. Example: 09/23/1975) *

Ethnicity *

Hispanic Non-Hispanic

Current Living Situation *

Household is extremely low-income. Household is homeless. Household is NOT low-income, but has been in the last 12 months. Household is NOT homeless, but has been in the last 12 months.

Are you currently working? *

Yes No

If yes, where? *

What is your position title? *

Are you currently in school? *

Yes No

If yes, where do you attend school? *

What are some of your goals for your life? *

Total Monthly Income *

Total Monthly Expenses *

If you receive child support or money outside of your normal wages, please include the monthly amount here: *

List children/people that live with you including unborn children: (Please list BIRTHDATES INCLUDING THE YEAR) *

List of Needs (Examples: Job Search Assistance, Food, Clothing, Furniture, Housing, Etc.) *

Additional Comments *

Resume Upload *

Max file size: 20MB

Certification of Application: I hereby certify that all the information I have provided in this form is true and accurate. I understand that if I do not provide all of the information requested that I might not be eligible for assistance. I understand that providing false information will result in my request form being denied or terminated. I understand that I may be required to verify the information provided here. I accept responsibility for keeping Shelter From the Rain Inc. informed of my current physical address and I understand that my application may be cancelled if I fail to do so. *

Confirm Deny

Submit