Red Mountain Grace
Rental Application
Guest Information:
Please input information for the main point of contact who will be staying in the apartment.
First Name
Last Name
Date of Birth
Phone Number
Email Address
Current Permanent Street Address
City
State
Zip Code
County
The Zip Code currently entered is not located within RMG's area of service. If you have questions regarding your eligibility, please feel free to email
admin@redmountaingrace.org.
Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander, or some other race?
Please select...
White
Black or African-American
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific islander
From multiple races
Other
Gender
Please select...
Female
Male
Other
Marital Status
Please select...
Married
Widowed
Divorced
Separated
Never Married
Education
Please select...
Less than high school degree
High school degree or equivalent (e.g., GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
Household Income
*this answer does not change our rate of $20/n
ight
Please select...
$20k or less
$20k - $40k
$40k - $60k
$60k - $80k
$80k - $100k
$100k - $200k
$200k - $300k
$300k+
Which of the following best describes you?
Patient
Caregiver
Patient Information:
Please provide more information about your loved one who is here for medical treatment.
First Name
Last Name
Date of Birth
Phone Number
Email Address
Current Permanent Street Address
City
State
Zip Code
County
Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander, or some other race?
Please select...
White
Black or African-American
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific islander
From multiple races
Other
Gender
Please select...
Female
Male
Other
Marital Status
Please select...
Married
Widowed
Divorced
Separated
Never Married
Education
Please select...
Less than high school degree
High school degree or equivalent (e.g., GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
Household Income
*this answer does not change our rate of $20/n
ight
Please select...
$20k or less
$20k - $40k
$40k - $60k
$60k - $80k
$80k - $100k
$100k - $200k
$200k - $300k
$300k+
Caregiver Information:
Please provide more information about your loved one who will be staying in the RMG apartment during your time in Birmingham.
First Name
Last Name
Date of Birth
Phone Number
Email Address
Current Permanent Street Address
City
State
Zip Code
County
Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander, or some other race?
Please select...
White
Black or African-American
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific islander
From multiple races
Other
Gender
Please select...
Female
Male
Other
Marital Status
Please select...
Married
Widowed
Divorced
Separated
Never Married
Education
Please select...
Less than high school degree
High school degree or equivalent (e.g., GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
Household Income
*this answer does not change our rate of $20/n
ight
Please select...
$20k or less
$20k - $40k
$40k - $60k
$60k - $80k
$80k - $100k
$100k - $200k
$200k - $300k
$300k+
More Information:
Reason in need of local lodging
Please select...
Bone Marrow Transplant
Bone Marrow Transplant - Pediatric
Cancer Treatment
Constraint Therapy
COVID
Eating Disorder Treatment
Heart Surgery
Heart Transplant
Heart Transplant - Pediatric
ICU
Kidney Transplant
Liver Transplant
Lung Transplant
LVAD
Neonatal ICU
Neuro ICU
Other
Premature Birth
Proton Therapy
Trauma
Hospital
Please select...
A Center for Eating Disorder
Brookwood Hospital
Children's Hospital
Grandview
St. Vincent's
UAB Hospital
Urology Centers of Alabama
VA
Other
Select Specialty - Brookwood
Social Worker
Insurance Policy Provider
Referring Physician
* By providing your
referring physician and
social worker's name you are giving Red Mountain Grace permission to contact them about the status of your medical care.
Will anyone other than those listed in this application be staying in the apartment?
Other Adults (Over 18 Years Old)
Children (Under 18 Years Old)
Other Adults Staying in Apartment:
Please provide information on any people
over
18 years of age
who will be staying in the apartment
First Name
Last Name
Date of Birth
Phone Number
Email Address
Current Permanent Street Address
City
State
Zip Code
County
Relation to you
Add an Additional Adult Guest
Yes
Other Adults Staying in Apartment:
Please provide information on any people
over
18 years of age
who will be staying in the apartment
First Name
Last Name
Date of Birth
Phone Number
Email Address
Current Permanent Street Address
City
State
Zip Code
County
Relation to you
Add an Additional Adult Guest
Yes
Other Adults Staying in Apartment:
Please provide information on any people
over
18 years of age
who will be staying in the apartment
First Name
Last Name
Date of Birth
Phone Number
Email Address
Current Permanent Street Address
City
State
Zip Code
County
Relation to you
Add an Additional Adult Guest
Yes
Other Adults Staying in Apartment:
Please provide information on any people
over
18 years of age
who will be staying in the apartment
First Name
Last Name
Date of Birth
Phone Number
Email Address
Current Permanent Street Address
City
State
Zip Code
County
Relation to you
Add a Child to Stay in the Apartment:
First Name
Last Name
Date of Birth
Relation to you
Add an additional child
Yes
Add a Second Child to Stay in the Apartment:
First Name
Last Name
Date of Birth
Relation to you
Add an additional child
Yes
Add a Third Child to Stay in the Apartment:
First Name
Last Name
Date of Birth
Relation to you
Add an additional child
Yes
Add a Fourth Child to Stay in the Apartment:
First Name
Last Name
Date of Birth
Relation to you
Add an additional child
Yes
Emergency Contact:
Please name someone who will not be residing in the apartment with you.
First Name
Last Name
Phone Number
Relationship
Other Information
What date do you need lodging?
Is this date dependent on discharge from the hospital?
Yes
No
Are you able to comfortably navigate stairs?
Yes
No
How many total guests will be staying full time in the apartment?
Any other relevant information that RMG should be aware of:
Upload a photo of your Driver's License
Check this box to acknowledge that all of the above information is accurate to the best of your knowledge and you are willing to subject yourself to a formal background check
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Contact Information