Emergency Housing Application

This application is the first step in seeking Emergency Housing.

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Applicant's Information
Name*
First Last
What City/State/Zip/Parish are you currently in?*
City State ZIP Code
Social Security Number*
Are you a Veteran?*
Are you a Registered Sex Offender?*
If you are, you aren't eligible for our program.
Are you physically capable of climbing into a top bunk?*
Are you willing to contribute here?*
We require you to participate in chores, work detail, and faith-based services. Also, once you start working you're required to contribute financially.
Date of Birth*
City of Birth*
State of Birth*
State
Marital Status*
Race*
Highest Level of Education Attained*
Are you employed?*
Monthly Income*
Source of Income*
Why do you need emergency housing?*
Explain your current situation.*
Your phone number/other way to contact you.*
Email Address

Alcohol and Substance Abuse Information
Have you struggled with Drug addiction in the past?*
Have you struggled with Alcohol addiction in the past?*
Briefly Describe Addiction Background*
Can you pass a drug/alcohol screen?*
If you can't pass a drug/alcohol screen when you arrive at the mission, you will still be allowed to stay but you can't leave our facility until you can pass one. If you are dishonest about your drug/alcohol usage on your application you won't be allowed to stay at intake time.
If No, List the drugs you will fail for?*
Answer "NA" if this doesn't apply to you.
Applicant Court, Parole, Probation Status and Information
Are you on Parole/Probation?*
If so, what were you charged with?*
Answer "NA" if you aren't on Parole/Probation.
Applicant Previous Residency Information
Where are you currently staying?*
Length of stay at prior residence?*
Have you ever been a resident of the Refinery Mission?*
This also includes our previous organization name , the Opelousas Lighthouse Mission.
If yes, what month and year?*
Answer "NA" if you've never been here before.
If yes, did you leave on good terms?*
The Refinery Mission does not discriminate on the basis of race, color, age, ethnicity, religion, national origin, sexual orientation, marital status, disability, or status as a U.S. veteran.

If you have any questions or concerns please feel free to call our office @ 337-948-8865 or email us at info@refinerymission.org.

Applicant's Information