Day Center Client ApplicationThe Kiosk Manage Orders Human Services: Clients Day Center Kiosk Primary Agency Providing Services arrowup6 Agency's Name Hosea Helps The Date Month * - Select -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year * - Select -20212022202320242025 Basic Information Are you in a vehicle today? * - Select -I'm walking.I'm in a vehicle. Prefix * - Select -Ms.Mrs.Mr. First Name * Last Name * Email Address Mobile Phone Number Street Address Unit Number City * State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOther Province Select a Georgia County * - Select -ApplingAtkinsonBaconBakerBaldwinBanksBarrowBartowBen HillBerrienBibbBleckleyBrantleyBrooksBryanBullochBurkeButtsCalhounCamdenCandlerCarrollCatoosaCharltonChathamChattahoocheeChattoogaCherokeeClarkeClayClaytonClinchCobbCoffeeColquittColumbiaCookCowetaCrawfordCrispDadeDawsonDeKalbDecaturDodgeDoolyDoughertyDouglasEarlyEcholsEffinghamElbertEmanuelEvansFanninFayetteFloydForsythFranklinFultonGilmerGlascockGlynnGordonGradyGreeneGwinnettHabershamHallHancockHaralsonHarrisHartHeardHenryHoustonIrwinJacksonJasperJeff DavisJeffersonJenkinsJohnsonJonesLamarLanierLaurensLeeLibertyLincolnLongLowndesLumpkinMaconMadisonMarionMcDuffieMcIntoshMeriwetherMillerMitchellMonroeMontgomeryMorganMurrayMuscogeeNewtonOconeeOglethorpePauldingPeachPickensPiercePikePolkPulaskiPutnamQuitmanRabunRandolphRichmondRockdaleSchleyScrevenSeminoleSpaldingStephensStewartSumterTalbotTaliaferroTattnallTaylorTelfairTerrellThomasTiftToombsTownsTreutlenTroupTurnerTwiggsUnionUpsonWalkerWaltonWareWarrenWashingtonWayneWebsterWheelerWhiteWhitfieldWilcoxWilkesWilkinsonWorth Other Province Zip Code Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Program Information arrowup6 Assign a Case Manager NoYes Case Status No Case Manager AssignedCase In ProgressCase SuspendedCase CancelledCase Successfully Closed Select Relevant Programs Back to School Children's Christmas Event Christmas Event Community Distribution Community Education COVID Response Day Center DeKalb District 7 Disaster Relief Financial Assistance Fresh Food Wednesdays MLK Jr. Holiday Mommy and Me No Summer Hunger Outreach to the Homeless Spring Event Thanksgiving Event Services Requested Select any services this household needs. Baby Items Blankets Clothing Counseling or Rehabilitation Emergency Shelter Employment Assistance Food and Beverages Get or Renew Food Stamps Medical Care Rent Assistance School Supplies Toiletries Toys Utility Assistance Summary of Services Provided arrowup6 Mark any services that were provided. Baby Items Barber and Beauty Services Clothing and Accessories Community Education Employment Assistance Food and Beverages Homeless Prevention Screening Medical Services Personal Care Items Referral to Another Agency Rent Assistance School Supplies SNAP Screening Toys Training Utility Assistance Additional Information arrowup6 Demographics Off On Household Off On Request SNAP Benefits Off On Demographics Low-Income Household * Yes No Resident of the City of Atlanta * Yes No Age 55 Years or Older? * Yes No Have a Savings Account? * Yes No Ethnicity? * African-American/Black American Indian Asian Hawaiian/Pacific Islander Hispanic White/Caucasian Gender? * Female Male Transgender Male to Female Transgender Female to Male US Citizen or Legal Immigrant? * Yes No Student? * Yes No Military Veteran? * Yes No Employed? * Yes No Retired Ever Been Homeless? * Yes No Survivor of Domestic Violence? * Yes No Are you currently experiencing domestic violence? * - Select -I am currently homeless because I am fleeing domestic violence.I am currently experiencing domestic violence.I have experienced domestic violence within the past year.I am not currently experiencing domestic violence. Current Housing Status? * - Select -At risk of losing my housing.Homeless: Living on the StreetHomeless: Living in a VehicleHomeless: Living in a ShelterHomeless: Living in a HotelHomeless: Living in Transitional HousingLiving with family and friends.Stable in my own home. Use Public Transportation Weekly? * Yes No Have a Disabling Condition? * Yes No Have Health Insurance? * Yes No Household Snapshot Total People in Household * Minors Under 18 * Seniors 55 and Older * Are you at risk of being evicted? * - Select -YesNo At risk of utilities being disconnected? * - Select -YesNo Request SNAP Benefits Select any benefits you would like to apply for. * Food Stamps TANF Medicaid CAPS Medicare Women's Health Coverage (Ages 19-44) None of the Above Administrative Panel arrowup6 Entry From Kiosk NoYes Date Stamp Do not edit. Time Stamp Do not edit. Client ID Do not edit. Format: Last Name, First Name, Email Send If you are human, leave this field blank. Thank you! Powered By Hosea Helps