Become a Client of The Shepherd’s Center of Greater Tupelo

Name

Address

City

Zip Code

Phone (home)

Phone (mobile)

Email Address

Date of Birth

Preferred Contact Method Preferred Contact Method Phone Email

How did you hear about the Shepherd's Center?

Emergency Contact Name

Emergency Contact Phone

Relationship

Emergency Contact Address (Address and City)

Are there any specific instructions for volunteers who will come to your home (such as places to park, doors to use, access codes, pets in the home, or other instructions)?

If a volunteer shows up for a scheduled appointment and there is no answer at your door, what would you like our volunteer to do? If a volunteer shows up for a scheduled appointment and there is no answer at your door, what would you like our volunteer to do? Call the Emergency Contact Listed Contact someone who has access to the home

Who else can we contact that has access to your home? (Please list name and phone number)

Living Arrangement Living ArrangementAloneAssisted LivingFamilyNursing HomeSection 8/Law Income Housing

With which Race/Ethnicity do you most identify? With which Race/Ethnicity do you most identify?African AmericanAmerican IndianAsianCaucasianHispanicNative Hawaiian/Pacific IslanderOther