Application for Services

First Name

Last Name

Date of Birth

month/day/year (MM/DD/YYYY)

Gender

Family Type

Marital Status

Partner's Name

What is your preferred language?

Race/Ethnicity

Highest Level of Education

Email Address

Preferred Phone Number

May we call or text you for scheduling, reminders, and updates ? By selecting yes, you agree to receive text messages from CRCTV related to the services you request. Message & data rates may apply. Message frequency varies. You may reply STOP at any time to cancel. View Privacy Policy here.

YesNo

Physical address

City

State

Zip Code

Is your mailing address the same as the physical address listed above?

YesNo

Mailing Address

Street Address

City

State

Zip Code

Do you identify as a person with a disability?

YesNo

Do any of these conditions keep you from working?

YesNo

Are you... (select all that apply)

A veteranA studentPregnant

In case we can't reach you, please include a back up contact information.

Name

Phone Number

Relationship

How long have you lived in Teton Valley?

How did you hear about the CRCTV?

Who referred you?

Have you received assistance from other Teton County, ID agencies/organizations?

YesNo

Have you received assistance from other Teton County, WY agencies/organizations?

YesNo

Housing & Household

What is your current housing situation?

Are you worried that in the next 2 months you may not have stable housing?

YesNo

Please explain:

How many other people do you live with?

Household Members

Name

Date of Birth

month/day/year

Relationship

Household Members

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Household Members

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Household Members

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Household Members

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Household Members

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Household Members

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Household Members

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Name

Date of Birth

month/day/year

Relationship

Landlord or Lender

Name

Phone Number

Mailing Address

How can we help you?

Please briefly describe your current situation.

What is your specific request from CRCTV? (Please check all that apply)

Confidentiality Statement and Consent to Release Confidential Information

I hereby state that the aforementioned is a complete and accurate representation of my situation. I understand that the Community Resource Center of Teton Valley (CRCTV) has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow CRCTV to release some of my personal information to certain individuals or agencies. I understand that the CRCTV is required by law to report this information to the police if there is evidence of the abuse or neglect of a child, an older adult, or other vulnerable parties; if I present a danger to myself or to others; or if there is a court order that requires disclosure of the information.

Release Authorization

Full Name

Date of Birth (month/day/year)

I hereby authorize CRCTV to release any information pertaining to me to the agencies/persons indicated below, and I also authorize the indicated sources to release information/documentation regarding my case to the CRCTV (please provide specific names, as needed):

Name

Phone

Relation

The duration of this authorization is for one year after the termination of my case. I understand that I may revoke this consent at any time by notifying the facility in writing or orally, except to the extent that action has already been taken in reliance on my consent. A photocopy of this authorization is to be considered as valid as the original document.

I understand that organizations and individuals that are not listed above may be contacted, but that only my general situation and no personal information will be shared with these entities unless I am applying to receive financial assistance of any kind.

If I am applying for financial assistance, I understand that CRCTV may need to speak to relevant agencies and individuals to seek out what resources might be available, to assess which community resources have already been used by me, and to inform those resources of the use of CRCTV funds to prevent duplication of services.

I understand that assistance rendered may not be solely monetary and authorize advocacy on my behalf. I understand that a committee makes the decision as to any assistance that I may receive from CRCTV and CRCTV intake agents do not have authority to, or capacity of, making immediate assistance available.

I have read the disclosure that appears above, I understand what I have read, and by my own will and with full knowledge I sign this document.

By typing your name below, you are accepting this as your electronic signature.

Full Name

Today's Date

Financial Assistance	Energy Assistance
Access to Healthcare	Housing
Case Management