Membership Application

Welcome to St. Mary's Center!
We are delighted that you are considering joining our community. At St. Mary's Center, we are committed to a community of hope, healing, and justice. Our senior center offers a variety of programs, activities, and services designed to enrich your life and support your well-being.
Membership Application
This application will take between 15-20 minutes to complete. If you are in need of housing services, the application may take slightly longer. Your responses will help us understand your needs and preferences, allowing us to provide you with the best possible experience.
Programs and Services:
Meals: Breakfast and lunch, 5 days a week and on Sundays
Activities: Bingo, Tai Chi, Cultural celebrations, cooking classes, computer classes
Support: Counseling services, housing navigation, transitional housing, housing deposits, tenancy sustaining supportive services, hotel vouchers (for eligible seniors), and general case management
Advocacy Groups: Council of Elders, Leadership Academy, and Hope & Justice

All our services are designed with seniors in mind, as we serve seniors aged 55 and older ONLY.
Thank you for taking the time to complete this application. We look forward to you joining our community!

Membership Application
Date*
MonthDayYear
Date
New or Returning Member*
Client ID Number
Client Name*
First NameMiddle NameLast NameSuffix
Preferred Phone
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Age *
Date of Birth*
MonthDayYear
Date
Preferred Language
Relationship Status
Email
example@example.com

Housing
Do You Have Housing?*
Address
Street Address
Street Address Line 2
CityStateZip Code
Is this your primary place of residence?
YesNo
Do You Live Alone?*
Household Size
Current Living Conditions*
Where can we locate you?
Mailing Address
Street Address
Street Address Line 2
CityStateZip Code

Client Details
Gender Identity
Sexual Orientation
Preferred Pronoun
Race
Source of Income
Employment Status
Do you have a second source of income?
Monthly Income
Secondary Source of Income
Health Insurance*
Other Health Insurance
Managed Care Provider
Veteran
YESNO
Discharge Status
Are you currently working with the Veterans Affairs (VA)?

Emergency Contact Information
Do you have someone we can contact in an emergency situation?
YESNO
Emergency contact First Name
Emergency contact Last Name
Emergency contact Relationship
Emergency contact Phone
Please enter a valid phone number.

Emergency Contact Address
Street Address
Street Address Line 2
CityStateZip Code

Community Standards Commitment

St. Mary's Center believes in every person's right to mutual peaceful enjoyment; fostering an environment that holds ALL in high regard, and genuinely respects differences in class, age, race, culture, gender, and beliefs. We also believe in a person's right to freedom from all forms of violence including the effects of poverty and homelessness. We are committed through policy, word, and action to create a clean and sober environment that is welcoming for all.

It is expected that the full St. Mary's Center community will practice high standards of behavior by:
- Always communicating with respect and dignity
- Showing support for each other while practicing self-care and healthy boundaries
- Demonstrating acceptance, empathy, inclusivity, non-judgment, and accountability
- Using the Grievance Process to work through challenges with staff and other members
It is expected that on St. Mary's Center ·properties staff, members, and non-members will NOT:
- Engage in verbal harassment including behavior that feels threatening to someone else and does not respond to de-escalation intervention
- Make physical threats, harassment, or physically assault individuals or property
- Use illegal substances or alcohol on St. Mary's Center grounds
- Smoke cigarettes or marijuana or display smoke paraphernalia
- Steal food or property including food and materials available for donations
- Sell or purchase illegal or prescription drugs
- Sell or purchase services or products, homemade or otherwise, from staff or members
- Will not borrow money or accept gifts of extraordinary value from staff or members
- Exhibit behavior that disturbs the peaceful enjoyment of community activities particularly, but not exclusively when under the influence of alcohol, and/or illegal substances including abuse of prescription medication
- Bring in weapons or materials that can be used as weapons, or brandish items as weapons.
- Those engaged in these behaviors will be asked to leave SMC immediately, and if appropriate, a re- unification strategy will be initiated.
I, {name3} agree to practice to the best of my ability the Community Standards outline above.

Signature* {date}

Art Work, Story, Photo and Video Media Release Form

St. Mary's Center shares images, stories and creative works by Seniors to increase awareness and educate our community on issues related to the extremely low-income seniors we serve and to promote the work of the agency. We respect each person's privacy regarding presenting personal work to the public.

I, _ {name3} _ give permission to be photographed and videotaped at events connected with St. Mary's Center and its affiliate. I understand that my image and creative work may be included in reports, publications, grants, news media, exhibits, websites, social media and other paper and Internet venues.

I give permission to St. Mary's Center to use my name as (check one)
- Full Name: First Name ONLYYesNo*
- Other Name 13
- I permit St. Mary's Center to use my artwork, writings, and storyYES NO
- I permit St. Mary's Center to use my image and voice in photos and videos:
- Yes No I prefer to remain anonymous
{name3}

Signature {date}

DISCLAIMER
We understand that the next set of questions are very personal and potentially triggering. These questions are designed to help us better understand your immediate safety and housing needs. Please answer only as you feel comfortable. Your responses will enable us to provide you with the best possible service.
Rest assured, your responses will be kept private and secure. Only authorized staff will have access to your answers, and they are committed to protecting your privacy.

Alameda Countywide InHOUSE HMIS – Release of Information
What is InHOUSE and Why Should I Use It?

InHOUSE is a database system used to:
- Coordinate efforts to help you obtain and maintain permanent housing
- Ensure these projects continue receiving funding to keep them open
- Secure files electronically
- Reduce the information you have to repeat and answer at multiple agencies
The InHOUSE system is used by many agencies throughout the county that provide services to homeless and low-income persons. A current list of participating health, housing, and human service agencies that provide housing-related supports is available at (acgov.org/cda/hcd/documents/roi_providers.pdf) . InHOUSE data is used to assess your needs, track and improve services provided, and to match you to helpful resources based on priorities and standards established by the Alameda County HUD Continuum of Care (viewable at everyonehome.org).

When you request or receive services from a program participating in the Alameda County Continuum of Care, information collected about your household is entered into the InHOUSE system.

What information is shared about me?

My name, social security number, alias, date of birth, gender, race, ethnicity, veteran status, education, employment, if I have a disability, household relationships, living situation, income amount(s) and type, benefit(s) information, if I have health coverage and type, assessments, services needed and provided, and outcomes of services provided, including the name of the projects where I received services. Other information that might be collected (dependent on program) include income, non-cash benefits, health insurance, physical disability, developmental disability, chronic health condition, HIV/AIDS status, mental health, substance abuse, domestic violence, sexual orientation, etc. Additional information may include sharing of my photo and previously collected InHOUSE data.

Who can view and share information about me?

Information shared about me will ONLY be viewable by the participating agencies listed at
(acgov.org/cda/hcd/documents/roi_providers.pdf). Each person or agency with access rights to the InHOUSE system must sign an agreement to maintain the security and confidentiality of client records.
Funders, cities, and other housing-related planning groups require InHOUSE to provide reports, which enable them to better understand the people-served, services provided and outcomes achieved. InHOUSE helps by pooling your data with others for these reports. This supports continued funding and improvement of services and housing projects for you and other homeless and low-income households. In addition, InHOUSE data is used for research purposes (including coordination with other systems of care), analysis about programs, specific service types, targeting of services, understanding best practices and improvements needed, or other uses to enhance the homeless and housing service delivery system. Keeping your information within the InHOUSE system helps us pool your data with others for these reports.

You have the right to receive a copy of all information collected about you and shared between the participating agencies. You may also amend and correct information collected about you that may be incorrect.

Client Name (Print): First Name   Last Name   Accompanying Children:______ if appropriate.

I have received and reviewed the “What is InHOUSE and Why Should I Use It” information sheet.    Signature

Alameda Countywide InHOUSE HMIS – Release of Information
Client Name (Print): First Name Last Name Accompanying children: _____________

I have received and reviewed the “What is InHOUSE and Why Should I Use It” information sheet. Signature

Consent to share and view my data:

By signing below, I agree that program intake/exit and service information collected about me and my household can be shared among InHOUSE participating agencies for the purposes of helping me to obtain and maintain permanent housing.
- I understand that a regularly updated list of the agencies participating in InHOUSE is available at (acgov.org/cda/hcd/documents/roi_providers.pdf).
- I know that the agencies participating in the system (listed at acgov.org/cda/hcd/documents/roi_providers.pdf) must follow strict privacy laws regarding protection of electronic and paper records.
- I understand that this acknowledgement is valid for ten (10) years from the date that I sign this form.
- I understand that my name, date of birth, gender and Social Security Number are used to identify my record in the database.
- I understand that my photo may be shared in the system.
- I understand that my services and project data will be used in reporting and in research or analysis about programs, specific service types, targeting of services, or other uses to improve the homeless and housing service delivery system.
Signature of Client*
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Date
Agency Representative
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Membership Application

How well do you agree with the following statements:

Alameda Countywide InHOUSE HMIS – Release of Information

Alameda Countywide InHOUSE HMIS – Release of Information