Apply for the Kelly Shelter

Kelly Shelter Application

Kelly Shelter is a year-round, low-barrier shelter in Medford, Oregon. This 64-bed facility provides an opportunity for our case management staff to meet daily with participants to help address individual barriers to permanent housing and self-sufficiency.

Step 1 of 13

Fill out the online application below (which may take between 30 minutes to an hour) or download and print the Kelly Shelter Application PDF.

Head of Household's full name(Required)

First Last

Alias

Date Received

Month

Day

Year

Mailing Address

Street Address City State ZIP Code

Email Address

Phone #

Text OK?

Yes

Individual 1

Please fill in your information first.

Name(Required)

First Last

Social Security #(Required)

OK to answer "Don't Know" or "Refused".

Are you a US Military Veteran?(Required)

Yes

Refused

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Check all that apply

M = Male

F = Female

TG = Transgender

NSG = No single/specific gender, non-binary, genderfluid, agender

Q = Questioning

DNK = Doesn't know

CR = Refused

Race(Required)

Check all that apply

American Indian / Alaskan Native / Indigenous

Asian or Asian American

Black, African American, or African

Native Hawaiian or Pacific Islander

White

Refused / Unknown

What is your primary race?(Required)

OK to answer "Don't Know" or "Refused".

Ethnicity: Are you Hispanic or Latino?(Required)

Yes

Refused

Household type(Required)

Check all that apply

SI : Single Individual

CNC: Couple No Children

FSP: Female Single Parent

MSP: Male Single Parent

TPF: Two Parent Family

GPC: Grandparent(s) and Child

FP: Foster Parent(s)

NCC: Non-Custodial Caregiver(s)

Refused / Don't Know

What is your relationship to the head of household?(Required)

Self

Head of Household's Child

Head of Household's Spouse or Partner

Head of Household's other relation member (Other relation to head of household)

Other: non-relation member

Refused

History of Homelessness

Where did you (and your family if they are with you) spend the night last night? Please be specific, you do not need to disclose your location but please indicate where.(Required)

Examples: Emergency Shelter, Hospital, Jail, Place not meant for habitation (Camp, Street, Car, etc.), with Family or Friends. OK to answer "Don't Know" or "Refused".

Length of stay in the place above? How long in a row is this homeless episode?(Required)

One day or less

2 days to one week

More than a week, less than a month

1-3 months

More than 3 months, less than a year

One year or longer

Don't Know

Refused

Other

Approximate date this current occurrence of homelessness started?

Month

Day

Year

How many times have you been on the streets, in ES = Emergency Shelter, or HS = Homeless Shelter in the past three years including today?(Required)

Don't Know

Refused

Total number of months experiencing homelessness in the last three years?(Required)

OK to answer "Don't Know" or "Refused".

Have you or your family ever received services from Rogue Retreat?(Required)

Yes

Don't Know

Refused

If yes, what services?

OK to answer "Don't Know" or "Refused".

Do you have a service animal or pet? If yes, what kind of animal and how many?(Required)

Yes

Refused

Kinds:

How many?

HEALTH INSURANCE

Do you have health insurance?(Required)

Yes

Don't Know

Refused

Who is your health insurance provider? Check one:(Required)

AllCare

Jackson Care Connect

Oregon Health Plan

Other

Don't Know

Refused

What is your insurance ID number?

OK to answer "Don't Know" or "Refused".

DISABILITY STATUS

Do you have a Disabling Condition?(Required)

Yes

Refused

Check all that apply below(Required)

Alcohol Use Disorder (HUD)

Drug Use Disorder (HUD)

Both Alcohol and Drug Use Disorder (HUD)

Developmental (HUD)

HIV / AIDS (HUD)

Mental Health Disorder (HUD)

Physical

Chronic Health Condition (HID)

Other

& Are you able to use a top Bunk?

Yes

NON-CASH BENEFITS

Do you receive Food Stamps?(Required)

Yes

Amount $(Required)

OK to answer "Don't Know" or "Refused".

Do you receive WIC?(Required)

Yes

Amount $(Required)

OK to answer "Don't Know" or "Refused".

INCOME

Do you receive any reliable income each month?(Required)

Yes

What is your source of income?

OK to answer "Don't Know" or "Refused".

Is there any other source of income?

OK to answer "Don't Know" or "Refused".

How much income do you have each month?

OK to answer "Don't Know" or "Refused".

Do you need to add another member?

Yes

Individual 2

Name(Required)

First Last

Social Security #

Is this person a US Military Veteran?

Yes

Date of Birth

Month

Day

Year

Gender

Check all that apply

M = Male

F = Female

TG = Transgender

NSG = No single/specific gender, non-binary, genderfluid, agender

Q = Questioning

DNK = Doesn't know

CR = Refused

Race

Check all that apply

American Indian / Alaskan Native / Indigenous

Asian or Asian American

Black, African American, or African

Native Hawaiian or Pacific Islander

White

Refused / Unknown

What is this person's primary race?

Ethnicity: Is this person Hispanic or Latino?

Yes

Refused

What is this person's relationship to the head of household?

History of Homelessness

Approximate date this current occurrence of homelessness started?

Month

Day

Year

How many times has this person been on the streets, in ES = Emergency Shelter, or HS = Homeless Shelter in the past three years including today?

Total number of months experiencing homelessness in the last three years?

HEALTH INSURANCE

Does this person have health insurance?

Yes

Who is this person health insurance provider? Check one:

AllCare

Jackson Care Connect

Oregon Health Plan

Other

What is this person insurance ID number?

DISABILITY STATUS

Does this person have a Disabling Condition?

Yes

Check all that apply below

Alcohol Use Disorder (HUD)

Drug Use Disorder (HUD)

Both Alcohol and Drug Use Disorder (HUD)

Developmental (HUD)

HIV / AIDS (HUD)

Mental Health Disorder (HUD)

Physical

Chronic Health Condition (HID)

& Is this person able to use a top Bunk?

Yes

NON-CASH BENEFITS

Does this person receive Food Stamps?

Yes

Amount $

Does this person receive WIC?

Yes

Amount $

INCOME

Does this person receive any reliable income each month?

Yes

What is this person's source of income?

Is there any other source of income?

How much income does this person have each month?

Do you need to add another member?

Yes

Individual 3

Name

First Last

Social Security #

Is this person a US Military Veteran?

Yes

Date of Birth

Month

Day

Year

Gender

Check all that apply

M = Male

F = Female

TG = Transgender

NSG = No single/specific gender, non-binary, genderfluid, agender

Q = Questioning

DNK = Doesn't know

CR = Refused

Race

Check all that apply

American Indian / Alaskan Native / Indigenous

Asian or Asian American

Black, African American, or African

Native Hawaiian or Pacific Islander

White

Refused / Unknown

What is this person's primary race?

Ethnicity: Is this person Hispanic or Latino?

Yes

Refused

What is this person's relationship to the head of household?

History of Homelessness

Approximate date this current occurrence of homelessness started?

Month

Day

Year

How many times has this person been on the streets, in ES = Emergency Shelter, or HS = Homeless Shelter in the past three years including today?

Total number of months experiencing homelessness in the last three years?

HEALTH INSURANCE

Does this person have health insurance?

Yes

Who is this person health insurance provider? Check one:

AllCare

Jackson Care Connect

Oregon Health Plan

Other

What is this person insurance ID number?

DISABILITY STATUS

Does this person have a Disabling Condition?

Yes

Check all that apply below

Alcohol Use Disorder (HUD)

Drug Use Disorder (HUD)

Both Alcohol and Drug Use Disorder (HUD)

Developmental (HUD)

HIV / AIDS (HUD)

Mental Health Disorder (HUD)

Physical

Chronic Health Condition (HID)

& Is this person able to use a top Bunk?

Yes

NON-CASH BENEFITS

Does this person receive Food Stamps?

Yes

Amount $

Does this person receive WIC?

Yes

Amount $

INCOME

Does this person receive any reliable income each month?

Yes

What is this person's source of income?

Is there any other source of income?

How much income does this person have each month?

Do you need to add another member?

Yes

Individual 4

Name

First Last

Social Security #

Is this person a US Military Veteran?

Yes

Date of Birth

Month

Day

Year

Gender

Check all that apply

M = Male

F = Female

TG = Transgender

NSG = No single/specific gender, non-binary, genderfluid, agender

Q = Questioning

DNK = Doesn't know

CR = Refused

Race

Check all that apply

American Indian / Alaskan Native / Indigenous

Asian or Asian American

Black, African American, or African

Native Hawaiian or Pacific Islander

White

Refused / Unknown

What is this person's primary race?

Ethnicity: Is this person Hispanic or Latino?

Yes

Refused

What is this person's relationship to the head of household?

History of Homelessness

Approximate date this current occurrence of homelessness started?

Month

Day

Year

How many times has this person been on the streets, in ES = Emergency Shelter, or HS = Homeless Shelter in the past three years including today?

Total number of months experiencing homelessness in the last three years?

HEALTH INSURANCE

Does this person have health insurance?

Yes

Who is this person health insurance provider? Check one:

AllCare

Jackson Care Connect

Oregon Health Plan

Other

What is this person insurance ID number?

DISABILITY STATUS

Does this person have a Disabling Condition?

Yes

Check all that apply below

Alcohol Use Disorder (HUD)

Drug Use Disorder (HUD)

Both Alcohol and Drug Use Disorder (HUD)

Developmental (HUD)

HIV / AIDS (HUD)

Mental Health Disorder (HUD)

Physical

Chronic Health Condition (HID)

& Is this person able to use a top Bunk?

Yes

NON-CASH BENEFITS

Does this person receive Food Stamps?

Yes

Amount $

Does this person receive WIC?

Yes

Amount $

INCOME

Does this person receive any reliable income each month?

Yes

What is this person's source of income?

Is there any other source of income?

How much income does this person have each month?

Do you need to add another member?

Yes

Individual 5

Name

First Last

Social Security #

Is this person a US Military Veteran?

Yes

Date of Birth

Month

Day

Year

Gender

Check all that apply

M = Male

F = Female

TG = Transgender

NSG = No single/specific gender, non-binary, genderfluid, agender

Q = Questioning

DNK = Doesn't know

CR = Refused

Race

Check all that apply

American Indian / Alaskan Native / Indigenous

Asian or Asian American

Black, African American, or African

Native Hawaiian or Pacific Islander

White

Refused / Unknown

What is this person's primary race?

Ethnicity: Is this person Hispanic or Latino?

Yes

Refused

What is this person's relationship to the head of household?

History of Homelessness

Approximate date this current occurrence of homelessness started?

Month

Day

Year

How many times has this person been on the streets, in ES = Emergency Shelter, or HS = Homeless Shelter in the past three years including today?

Total number of months experiencing homelessness in the last three years?

HEALTH INSURANCE

Does this person have health insurance?

Yes

Who is this person health insurance provider? Check one:

AllCare

Jackson Care Connect

Oregon Health Plan

Other

What is this person insurance ID number?

DISABILITY STATUS

Does this person have a Disabling Condition?

Yes

Check all that apply below

Alcohol Use Disorder (HUD)

Drug Use Disorder (HUD)

Both Alcohol and Drug Use Disorder (HUD)

Developmental (HUD)

HIV / AIDS (HUD)

Mental Health Disorder (HUD)

Physical

Chronic Health Condition (HID)

& Is this person able to use a top Bunk?

Yes

NON-CASH BENEFITS

Does this person receive Food Stamps?

Yes

Amount $

Does this person receive WIC?

Yes

Amount $

INCOME

Does this person receive any reliable income each month?

Yes

What is this person's source of income?

Is there any other source of income?

How much income does this person have each month?

By signing this application I understand that the information I provide will be entered into the ServicePoint HMIS database and my records will be updated as I receive services(Required)

I GIVE my permission to share this data with local agencies to better provide me care.

I DO NOT GIVE my permission to share this data.

Applicant's Full Name(Required)

Date(Required)

Month

Day

Year

Phone

This field is for validation purposes and should be left unchanged.

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