A Better Night's Sleep Application Step 1 of 4 25% Participation in this program is limited and will be filled on a first come, first served basis. At the end of this application you will be asked to upload the following documents. Please be prepared with pdf, png, gif or jpg copies of these files. A hand written letter stating why you need beds A copy of each child’s birth certificate OR proof of guardianship A copy of your valid photo ID A copy of your rental agreement A copy of your most current electric bill or most current phone bill A copy of food stamps letter, Medicaid letter, or any other form of government assistance Upon receipt of COMPLETE application and documentation, you will receive an appointment date within 30-60 days via mail or email. If your contact information changes (phone number or address), please call our office to update your information. By submitting this form you also agree to allow pictures of you and/or your children in any HCC publication.Contact InformationName* First Last Spouse Name First Last Address* Street Address Apartment # City TX AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Enter Email Confirm Email Home PhoneCell Phone*Work PhoneExtension Additional InformationMarital Status*MarriedSingle ParentDivorcedSeparatedLiving TogetherLanguage* English Spanish Rent Amount*Landlord's PhoneMonthly Household Income*Please include any government assistance. Please list your children's Information below:How many children are in your Legal Custody?*12345678910How many beds do you need?*012345678910Child/ Children must be between ages 4 and 18. There is a limit of 4 beds.Child's Name* First Last Age*456789101112131415161718Birth Date* Date Format: MM slash DD slash YYYY mm/dd/yyyyGender*MaleFemaleChild's Name First Last Age456789101112131415161718Birth Date Date Format: MM slash DD slash YYYY mm/dd/yyyyGenderMaleFemaleChild's Name First Last Age456789101112131415161718Birth Date Date Format: MM slash DD slash YYYY mm/dd/yyyyGenderMaleFemaleChild's Name First Last Age456789101112131415161718Birth Date Date Format: MM slash DD slash YYYY mm/dd/yyyyGenderMaleFemaleChild's Name First Last Age456789101112131415161718Birth Date Date Format: MM slash DD slash YYYY mm/dd/yyyyGenderMaleFemaleChild's Name First Last Age456789101112131415161718Birth Date Date Format: MM slash DD slash YYYY mm/dd/yyyyGenderMaleFemaleChild's Name First Last Age456789101112131415161718Birth Date Date Format: MM slash DD slash YYYY mm/dd/yyyyGenderMaleFemaleChild's Name First Last Age456789101112131415161718Birth Date Date Format: MM slash DD slash YYYY mm/dd/yyyyGenderMaleFemaleChild's Name First Last Age456789101112131415161718Birth Date Date Format: MM slash DD slash YYYY mm/dd/yyyyGenderMaleFemaleChild's Name First Last Age456789101112131415161718GenderMaleFemaleBirth Date Date Format: MM slash DD slash YYYY mm/dd/yyyy Please provide the following documents:A copy of your valid ID* Drop files here or Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx. A hand written letter stating why you need beds* Drop files here or Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx. A copy of your rental agreement* Drop files here or Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx. A copy of your most recent electric bill or most recent phone bill* Drop files here or Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx. A copy of food stamps letter, Medicaid letter, or any other form of government assistance* Drop files here or Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx. A copy of each child's birth certificate OR proof of guardianship* Drop files here or Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx. CAPTCHA
