Housing Intake Form: Longer Term Secure Short Term (LTSST)
Inviting community to co-create housing security in the most uncertain of times.
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Last Name *
First Name *
Hotel or Property Name (if applicable)
Email Address *
Phone *
Phone 2
Address (Street) *
Address (City) *
Minimum Length of stay offered? (LTSST is seeking minimum of 1-6 month offers) *
Required
Details to share about length of accommodation:
Type of Housing: *
Required
If Rooms in a shared home, how many?
Number of people able to accommodate: *
Will the above space be shared? *
If shared, with whom (including pets)?
Square footage of space (roughly)
Bedrooms available to evacuees *
Bathrooms available to evacuees *
Sleeping Accomodations (beds/pullout couches/sleeping bags, etc.) *
Furnished: *
Amenities:
Animal Friendly: *
If yes, types of animals welcome
Floors:
Clear selection
Financial Responsiblity of Occupants: *
Speak Spanish? *
Smoking allowed? *
Are you the owner of the property? *
If not the owner, do you have permission to lend the space?
Clear selection
ADA Compliant/ Wheelchair Accessible? If not, could it be accessible with minor alterations to amenities and entryways? *
Air quality (smoke): Does it need an air purifier? Does it have one? *
Date Available *
MM
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DD
/
YYYY
Please describe a little about yourself and anything you believe will help us gain a sense of you and the space you are offering. Include what you imagine to be a best fit for you, and your intentions for the level of security, safety, comfort and sense of belonging that the Rogue Valley community members who’ve lost everything by the Almeda Fire will receive by choosing to live in the dwelling(s) you are offering *
Any concerns, limitations, or stipulations you have? *
How did you come across this form? *
Any other pertinent information you would like to share with us:
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