Home
About
Services
blog
Contact
Login
Register
X
Facebook
Twitter
Youtube
This content is password protected. To view it please enter your password below:
Password:
Testing
HMIS#:
Date
Move-in Date
Name
D.O.B
Age
Cell Number
Email Address
Emergency Contact
Cell #:
Family Size
Are You Pregnant?
Yes
No
Expected Due Date
Source of Income:
CAL Works
General Relief
Food Stamps
Child Support
SSI / SSDI
Employed
Unemployed
Other
Other
Monthly Income
Pay Date (S):
Saving Pledge
Children Name 1
Children D.O.B 1
Children Age 01
Children Sex 1
Children Disability 01
Yes
No
Children Bed Wetter 1
Yes
No
Children Name 2
Children D.O.B 2
Children Age 02
Children Sex 2
Children Disability 2
Yes
No
Children Bed Wetter 2
Yes
No
Children Name 3
Children D.O.B 3
Children Age 03
Children Sex 3
Children Disability 3
Yes
No
Children Bed Wetter 3
Yes
No
Children Name 4
Children D.O.B 4
Children Age 04
Children Sex 4
Children Disability 4
Yes
No
Children Bed Wetter 4
Yes
No
Children Name 5
Children D.O.B 5
Children Age 05
Children Sex 5
Children Disability 5
Yes
No
Children Bed Wetter 5
Yes
No
If you are human, leave this field blank.
Submit
NRI- Families Application 95th
Page 2
Page 3
Page 4
Page 5
0% Complete
1 of 5
First & Last Name
*
Social Security #
Date
Ethnicity
Cell Phone #
Email Address
Date of Birth
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Name
Emergency Contact Phone
Citizenship Status
Citizen
Legal Resident
Undocumented
If you are human, leave this field blank.
Next
NRI- Singles Application 95th.pdf
PARTICIPANT APPLICATION
TRANSFORMING LIVES & RENEWING THE INNER YOU
First & Last Name
*
First & Last Name
First & Last Name
First & Last Name
Social Security
Date
Ethnicity
Cell Phone
Email Address:
Date of Birth
Emergency Contact Name
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Name
Emergency Contact Phone
Citizenship Status
Citizen
Legal Resident
Undocumented
If you are human, leave this field blank.
Next
NRI- Intake Singles 95th
NRI- Intake Singles 95th
HMIS#:
DATE
D.O.B.
AGE
CELL NUMBER
E-Mail Address
EMERGENCY CONTACT:
CELL #
FAMILY SIZE:
ARE YOU PREGNANT
Yes
No
EXPECTED DUE DATE:
SOURCE OF INCOME:
CAL WORKS
GENERAL RELIEF
FOODSTAMPS
CHILD SUPPORT
SSI / SSDI
EMPLOYED
UNEMPLOYED
OTHER
OTHER
MONTHLY INCOME
PAY DATE(S)
SAVINGS PLEDGE
ADULTS CIRCUMSTANCES DETAILS # 1
DCFS CASE
Yes
No
If you answered YES Provide Name (s)
ADULTS CIRCUMSTANCES DETAILS # 2
PROBATION CASE
Yes
No
If you answered YES Provide Name (s)
ADULTS CIRCUMSTANCES DETAILS # 3
CUSTODY ORDER
Yes
No
If you answered YES Provide Name (s)
ADULTS CIRCUMSTANCES DETAILS # 4
RESTRAINING ORDER
Yes
No
If you answered YES Provide Name (s)
*Custody & Restraining Orders Provide Copies
*
ADULTS DISABILITIES / MEDICAL CONDITIONS # 1
PHYSICAL
Yes
No
If you answered YES Provide Name (s)
ADULTS DISABILITIES / MEDICAL CONDITIONS # 2
MENTAL
Yes
No
If you answered YES Provide Name (s)
ADULTS DISABILITIES / MEDICAL CONDITIONS # 3
MEDICATIONS
Yes
No
If you answered YES Provide Name (s)
Please list medications and dosage.
If you are human, leave this field blank.
Submit
NRI- Intake Families 85th
HMIS#:
DATE
MOVE-IN-DATE
Name
D.O.B.
AGE
CELL NUMBER
E-Mail Address
EMERGENCY CONTACT:
CELL #
FAMILY SIZE:
ARE YOU PREGNANT
Yes
No
EXPECTED DUE DATE:
SOURCE OF INCOME:
CAL WORKS
GENERAL RELIEF
FOODSTAMPS
CHILD SUPPORT
SSI / SSDI
EMPLOYED
UNEMPLOYED
Other
Other
MONTHLY INCOME
PAY DATE(S)
SAVINGS PLEDGE
CHILDREN DETAILS #1
Name
D.O.B
AGE
SEX
DISABILIT
yes
No
BED WETTER
Yes
No
CHILDREN DETAILS # 2
NAME
D.O.B
AGE
SEX
DISABILIT
Yes
No
BED WETTER
Yes
No
CHILDREN DETAILS # 3
Name
D.O.B
AGE
SEX
DISABILITY
Yes
No
BED WETTER
YES
No
CHILDREN DETAILS # 4
NAME
D.O.B
AGE
SEX
DISABILITY
Yes
No
BED WETTER
Yes
No
CHILDREN DETAILS # 5
NAME
D.O.B
AGE
SEX
DISABILITY
Yes
Ni
BED Wetter
Yes
No
ADULTS CIRCUMSTANCES DETAILS # 1
DCFS CASE
Yes
No
If you answered YES Provide Name (s)
ADULTS CIRCUMSTANCES DETAILS # 2
PROBATION CASE
Yes
No
If you answered YES Provide Name (s)
ADULTS CIRCUMSTANCES DETAILS # 3
CUSTODY ORDER
Yes
No
If you answered YES Provide Name (s)
ADULTS CIRCUMSTANCES DETAILS # 4
RESTRAINING ORDER
Yes
No
If you answered YES Provide Name (s)
*Custody & Restraining Orders Provide Copies
*
ADULTS DISABILITIES / MEDICAL CONDITIONS # 1
PHYSICAL
Yes
No
If you answered YES Provide Name (s)
ADULTS DISABILITIES / MEDICAL CONDITIONS # 2
MENTAL
Yes
No
If you answered YES Provide Name (s)
ADULTS DISABILITIES / MEDICAL CONDITIONS # 3
MEDICATIONS
Yes
No
If you answered YES Provide Name (s)
Please list medications and dosage.
If you are human, leave this field blank.
Submit
NRI- Families Application 85th
PARTICIPANT APPLICATION
TRANSFORMING LIVES & RENEWING THE INNER YOU
Name
Name
First Name
First Name
Last Name
Last Name
Social Security #
Date
Ethnicity
Cell Phone #
Email Address
Date of Birth
Emergency Contact Name
Emergency Contact Phone
Citizenship Status
Citizen
Legal Resident
Undocumented
Undocumented
Emergency Contact Name
Emergency Contact Phone
Citizenship Status
Citizen
Legal Resident
Undocumented
Undocumented
Emergency Contact Name
Emergency Contact Phone
Citizenship Status
Citizen
Legal Resident
Undocumented
Undocumented
If you are human, leave this field blank.
Next
NRI-Contract Singles 85TH
INTERIM HOUSING CONTRACT AGREEMENT
TRANSFORMING LIVES & RENEWING THE INNER YOU
This Agreement shallbeevidencethat the complete terms and conditions under which the parties whosesignatures appear below have agreedupon Temporary Interim HousingProgram.New Reflections, Inc.located at8501 ½ S. Vermont Ave.in the city ofLos Angeles, CA.90044
TERMS
NRI Participant understands that housing is t emporary not perman ent and could be terminated by the funder or New Reflections, Inc. without notice based on funding or failure to adhere to ALL p rogram rules set forth by the funder and New Reflections, Inc
I further understand there are no overnight passes except on emergency basis. Example of emergenc ies : (Hospitalization/Emergency Room or Family Death) provide proof to NRI Staff immediat ely upon your return to the facility.
This agreement shall commence on
PETS
No animal, fowl, fish, reptile, and/or pet of any kind shall be kept on or about the premises
ALTERATIONS
Participant shall not paint, color or ink on walls, wallpaper, alter or redecorate, change or install locks, install antenna or other equipment, screws, fastening devices, large nails, or adhesive materials, place signs/photos, displays, or ot her exhibits, on or in any portion of the premises.
.
FACILITY RULE
NRI Participant shall comply with all Interim Housing Program rules as stated on separat e adde ndum, but which are deemed part of this Interim Housing Agreement, and a vio lation of any of the Interim Housing Rules is considered a breach of this agreement and you will be required to move out immediately
NOISE
NRI Participant agrees not to cause or allow any noise or activity on the premises which might disturb the peace and quiet of another Participant and/or neighbors within the community. Said noise and/or activity shall be immediate termination of this agreement & you must exit facility. EXAMPLE OF LOUD NOISE (e.g. music, yelling, running, screaming, use of profanity, etc.)
CONDITION OF PREMISES
NRI Participant acknowledges that she has examined the premises and that said premises, all furnishings, bins, lockers, fixtures, furniture, plumbing, heating, electrical, windows, walls, bedding , wa ll pictures and/or all other items provided by NRI are all clean, and in good satisfactory condition. Participant agrees to keep the premises and all items in good order and condition and to immediately pay for costs to repair and/or replace any portion of the above damaged b y NRI - Participant
INSURANCE
NRI Participant acknowledges that NRI insurance does not cover personal property damage cause d by fire, theft, rain, war , acts of God (death), acts of others, and/or any other causes, nor shall NRI be held liable for such losses.
AT
TORNEY FEES:
If any legal action s or proceedings be brought by this Temporary Interim H ousing Agreement, the NRI Participant shall be responsible for all attorney's fees, court fees and costs in addition to other damages awarded.
NRI PARTICIPANT AGREES
:
I will participate in activities identified in the case management plan and weekly goals I set forth to secure permanent housing and I shall participate in scheduled meetings with my case manager and weekly facility meetings. b. I shall immediately notify NRI Staff of an y circumstance(s) or event(s) that would prevent my compliance with the terms and conditions of this Interim Housing Agreement Example : (Overnights , change work schedule ) INTERIM HOUSING CONTRACT AGREEMENT TRANSFORMING LIVES & RENEWING THE INNER YOU c . I understand that I shall maintain a safe, clean, clut ter - free room and orderl y room for myself and that I am required to wash my own personal belongings once a week ( or immediately due to accidents , sickness, etc.). d. I understand that I shall refrain from any form of violence towards staff or others , verbal threats; including abusive language/profanity or other forms of intimidation during my participation with this program. e. I shall refrain from damaging or defacing of NRI property. Damaging or defacing of NRI property will result in immediate termination. I understand this wi l l result in immediate termination from the program and/or possible criminal actions. f. I understand that NRI will not be held liable for an y death, accidents and/or occurrences which may occur to me, e.g., slips, any falls and or falls in the showers, stairs, hallways, etc. g. I understand I shall refrain from all inappropriate sexual comments, or touching other participants either in a sexual manne r , or with the intent of harming and doing bodily harm will result in immediate termination. h . I shall not participate in any unlawful and/or illegal activity. i. I u n derstand I shall sign in at the appropriate time daily before 8am , D aily Si gn- in S heet & Meal Distribution Log writing neatly & legible . I f reminded to do so by NRI - Staff Participant agrees to do so without hesitation or confrontation . I f not , this agreement will be terminated.
PHOTOS/SOCIAL MEDIA/VIDEOCONSENT
I hereby grant to N RI permission to use my self or likeness i n photographs and/or video in any and all of its publications and in any and all other media, whether now known or he r eafter existing, controlled by NRI . I also understand that no royalty, fee or ot her compensation shall become payable to me by reason of such use
JOINTLY AND SEVERALLY
The undersigne d NRI Participant is jointl y and severall y responsible and liable for all obligations under this Temporar y Interim Housi ng Agreement.
AGREEMENT TERMINATION
NRI - HAS THE RIGHT T O TERMINATE THIS A GREEMENT AT ANYTIME OF D AY OR NIGHT DUE TO: { 1. NON -C OMPLIAN CE 2. S ERIOUS VILOLATION OF NRI INTERIM PROG RAM RULES & REQUIREMENTS OUTLIN ED IN THI S AGREEMENT}
I understand and agree up on my termination/exiting this program I will remove all of my person al belongings up on my exit date. If I leave any of my personal belongings behind it will bediscardedwithin24hoursofexitingunlessarrangementsaremade&agreed upon by NRI Staff.
NRI is n ot re sponsible fo r any of your personal belongings left behind. NRI -i s not a storage
I hereby acknowledge I have received New Reflections , Inc . Interim Housing Program Rules and Safety.
I hereby acknowledge I have received New Reflections , Inc . Interim Housing Program Rules and Safety.
By signing this agreement, all parties agree to the terms and conditions as described above.
The
undersigned NRI Participant has read and understands Temporary Interim Housing Agreement and
hereby agrees to comply with all informa
tion outlined in this Agreement
I Can Read
I Understand
I Agree to adhere to this Agreement
NRI Participant Print Full Name
NRI Participant Signature
Today’s Date:
NRI Staff Print Name & Title
NRI Staff Signature
Today’s Date:
If you are human, leave this field blank.
Submit
NRI- Singles Application 85th
Name
Name
First
First
Last
Last
First & Last Name
Date
Ethnicity
Cell Phone
Email Address
Date of Birth:
TRANSFORMING LIVES & RENEWING THE INNER YOU 1
Emergency Contact Name
Emergency Contact Phone#
Citizenship Status
Citizen
Legal Resident
Undocumented
Undocumented
TRANSFORMING LIVES & RENEWING THE INNER YOU 2
Emergency Contact Name
Emergency Contact Phone#
Citizenship Status
Citizen
Legal Resident
Undocumented
Undocumented
TRANSFORMING LIVES & RENEWING THE INNER YOU 3
Emergency Contact Name
Emergency Contact Phone#
Citizenship Status
Citizen
Legal Resident
Undocumented
Undocumented
If you are human, leave this field blank.
Next
NRI- Intake Singles 85th
NRI- Intake Singles 85th
HMIS#:
DATE
D.O.B.
AGE
CELL NUMBER
E-Mail Address
EMERGENCY CONTACT:
CELL #
FAMILY SIZE:
ARE YOU PREGNANT
Yes
No
EXPECTED DUE DATE:
SOURCE OF INCOME:
CAL WORKS
GENERAL RELIEF
FOODSTAMPS
CHILD SUPPORT
SSI / SSDI
EMPLOYED
UNEMPLOYED
OTHER
OTHER
MONTHLY INCOME
PAY DATE(S)
SAVINGS PLEDGE
ADULTS CIRCUMSTANCES DETAILS # 1
DCFS CASE
Yes
No
If you answered YES Provide Name (s)
ADULTS CIRCUMSTANCES DETAILS # 2
PROBATION CASE
Yes
No
If you answered YES Provide Name (s)
ADULTS CIRCUMSTANCES DETAILS # 3
CUSTODY ORDER
Yes
No
If you answered YES Provide Name (s)
ADULTS CIRCUMSTANCES DETAILS # 4
RESTRAINING ORDER
Yes
No
If you answered YES Provide Name (s)
*Custody & Restraining Orders Provide Copies
*
ADULTS DISABILITIES / MEDICAL CONDITIONS # 1
PHYSICAL
Yes
No
If you answered YES Provide Name (s)
ADULTS DISABILITIES / MEDICAL CONDITIONS # 2
MENTAL
Yes
No
If you answered YES Provide Name (s)
ADULTS DISABILITIES / MEDICAL CONDITIONS # 3
MEDICATIONS
Yes
No
If you answered YES Provide Name (s)
Please list medications and dosage.
If you are human, leave this field blank.
Submit
NRPA-Security Shift Report
SECURITY GUARD NAME
SITE NAME:
DATE
DAY
Mon
Tue
Wed
Thur
Fri
Sat
Sun
SHIFT
Day
Swing
Night
SHIFT DETAIL
TIME OF SHIFT
SECURITY GUARD MUST LOG EACH PATROL, SECURITY CHECK AND ALL PERTAINING INFORMATION
Add
Remove
SECURITY GUARD In a Case of Emergency, Call 911. REPORT IMMEDIATELY TO YOUR SUPERVISOR: FIRE, HOSPITALIZATION, DEATH, POLICE INVOLVEMENT, THEFT OR VANDALISM.
SECURITY GUARD SIGNATURE
If you are human, leave this field blank.
Submit
NRPA-Request-Off
Guard’s Name
Date
Time-Off Request Number of:
Days
Hours
Beginning On
Ending On
Reason for Request
Vacation
Personal Leave
Funeral / Bereavement
Jury Duty
Family Reasons
Medical Leave
To Vote
Other
Other
I understand that this Request is Subject to Approval.
*Please Give Proper Notification for Time Requesting Off.
Supervisor Decision
Approved
Rejected
Supervisor’s Signature
Date
Supervisor’s Comments
If you are human, leave this field blank.
Submit
