Surviving The Streets - Vital Information
Tool 4: A Record Of One's Vital Information
- Complete the Following.
- 2. Carry one copy on your person.
- 3. Leave another copy on file with Friendship House.
| Date:___________ | |
| Staff Contact: | ______________________________ |
| | |
| Name: | _______________________________ |
| Social Security Number: | ______- ____ - ________ |
| Birth date:__/__/_____ | PLACE OF BIRTH:___________ |
| Marital Status: _________ | |
| | |
| I Possess The Following Forms of Identification: | |
| Birth Certificate |
| S.S. N. Card |
| Delaware State I.D. Card |
| Delaware State Driver's License |
| Another State's ID Card |
| Another State's Driver's License |
| Welfare ID Card |
| Other: |
|
| Yes | No |
| Yes | No |
| Yes | No |
| Yes | No |
| Yes | No |
| Yes | No |
| Yes | No |
| Yes | No |
|
| | |
| If I Own A Vehicle? | |
| License Number: ________________ | Is It Insured?__________________ |
| Is It working?____________________ |
Do I Have Access To It? _______________ |
| | | | |
| Dependents: | | | |
| Name | Relationship | Social Security Number | Birth Date |
| 1. | | | |
| 2. | | | |
| 3. | | | |
| 4. | | | |
| 5. | | | |
| 6. | | | |
| | |
| CURRENT RESIDENCE: | |
| Program/Landlord: __________________________ | Phone ________________ |
| Address: _________________________________________ _________________________________________ | Length of Stay: |
| | |
| PRESENT OCCUPATION: | |
| Income | Job: | School: | Other: |
| Address: | | | |
| Phone: | | | |
| Cost: | | | |
| | | | |
| | |
| Emergency Contact: | |
| Name:__________________________ | Relationship:_____________ |
| Address:_________________________ | Phone:_______________ |
