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Program Application
APPLICATION
Please complete and submit the following application to be considered for acceptance into Camp Haven.
First Name
Email Address
Middle Initial
Date of Birth
Last Name
Phone Number
Emergency Contact
Emergency Contact Phone #
Relationship
Are you currently homeless?
Choose an option
Marital Status
Choose an option
# of Children
Are you an Indian River County resident?
Choose an option
If you are a resident, for how long?
Last Street Address
City
State
Zip code
How Long Did You Live There?
Are you a Veteran?
Choose an option
If a Veteran, # of Years in the Service?
How did you Hear about Camp Haven?
Can you work?
Choose an option
Are you currently employed?
Choose an option
If employed, how many hours per week?
If you're not employed, when did you work last?
Type of work you last did?
Highest Education Certificate Received
Choose an option
Have you ever been incarcerated?
Choose an option
If yes, how many times?
If yes, for how long?
Date of Release
Are you aware you will be drug tested now and later?
Choose an option
Where were you released from?
Are you aware that Camp Haven is a Program?
Choose an option
You are fully committed to participating in our program that provides: education, housing, meals, mandatory meetings, job skills preparation & healthcare referrals, abide by rules & curfews, room inspections, etc. You will have campus chores & you will pay rent regularly when you get a job.
Choose an option
Your Signature
Clear
Select a date
Send
Thank you for applying. Camp Haven Board, Staff & Partners are committed to helping you achieve your goals.
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