Shelter Service Request


Service Request Form
	Please provide the following information. ALL INFORMATION IS CONFIDENTIAL 89 North St. Burlington, VT 05401 802.862.9879
Submitted By:
First Name:
Middle Initial:
Last Name:
Last Address:
City:
State:
Zip:
Phone:
Mobile:
Email:
SSN: 000-00-0000
DOB: mm/dd/yy
Gender:
Age:
	- I am requesting Shelter services for myself.
	- I am interested in the Good Neighbor Program.
	Substance Abuse & Corrections Information
Alcohol Abuse:	- I have a history of alcohol abuse.
Drug Abuse:	- I have a history of drug abuse.
Corrections:	- I have a corrections background.
Medication:	Enter all meds you are taking...
Message:


"Working together as a community to meet the body, mind, and spiritual needs of Burlington's homeless"