IVC Housing Screening Form

Please complete answer the questions below so that we can connect you to our housing services.

Date Date / MM / DD YYYY
Name Name First Last
Phone Phone - ### - ### ####

Please ensure that we can call you at this number.
Email

We will contact you via email, please check that your email is correct.
G#
Are you currently experiencing homelessness?
Check only ONE of the following

Are you currently experiencing homelessness?
Check only ONE of the following Yes, I do not have a place to stay at (i.e. living in car, couch surfing, shelter surfing, staying at the park, etc.) No, but I am at risk for eviction within the next 2-3 days. No, but I am behind on rent. No, but I feel unsafe at home. None of the above Other Other
Are you currently experiencing food insecurity?
Check only ONE of the following:

Are you currently experiencing food insecurity?
Check only ONE of the following: Yes, I am experiencing hunger and I do not have CalFresh benefits. Yes, I have some food but not enough to carry me through the month and/or I have run out of CalFresh benefits for this month. No. I am not experiencing food insecurity. Other Other
Do you identify as any of the following groups:
Check ALL that apply:

Do you identify as any of the following groups:
Check ALL that apply: Foster Youth or Former Foster Youth Black/African American LGBTQIA Veteran Disabled None of the above apply to me.
Do you identify as any of the following groups:
Check ALL that apply:

Do you identify as any of the following groups:
Check ALL that apply: DACA First Generation Formerly Incarcerated Single Parent Student Athlete None of the above groups apply to me.
Are you a part of any of the following programs?

Are you a part of any of the following programs? EOPS/CARE DSPS CalWORKS Student Support Services (TRIO) Student Equity & Achievement (SEA) Restorative Justice Program Resilient Scholars Program PUENTE Program Military and Veterans Other Other
Are you being referred by a program/agency? If yes please enter that program here:
Is there anything else you would like to share with us?
By checking this form you consent to allow IVC Faculty/Staff/Administrators to disclose information regarding your IVC educational experiences/services.

By checking this form you consent to allow IVC Faculty/Staff/Administrators to disclose information regarding your IVC educational experiences/services. I consent. I decline.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. I understand that submission of this form is for screening purposes and that it does not automatically guarantee housing. Clear

Full Name

I understand this is a legal representation of my signature. I understand that submission of this form is for screening purposes and that it does not automatically guarantee housing.