Dream Center Golden Triangle

Please note: these beds are provided for emergency needs only.

Apply for the Bedz 4 Kidz program by filling out the following form. You must be at least 18 years of age to apply.

By submitting the Bed Request form below, you agree to the following:

I agree that if I receive assistance from The Dream Center Golden Triangle, I agree to the following: • There is no guarantee of assistance • Assistance is provided on a FIRST COME, FIRST SERVED basis. The undersigned recipient certifies that the information/answers provided are complete and true.

I further agree to the following: To relinquish this non-profit of all liability of any nature whatsoever. • To provide all requested documentation. • To utilize bed(s) for the purpose in which they are requested.

This non-profit WILL NOT: • Refuse assistance to you based on race, color, age, religion, national origin, disability, gender, sexual orientation or political affiliation. • Use or disclose your personal information for purposes other than those for which it has been collected, except with your consent, or as required or permitted by applicable law.

First Name
Last Name
Phone
Email
Street
City
State/Province
Zip
Date of Birth:
How many beds do you need?:
List children age and gender:
What is the reasoon for this request?:
Have you ever received assistance from DreamCenter?:
What is your monthly income?:
Marital Status:
Ethnicity:
Are you a Veteran?:
Are you Home bound?:
Do you receive Public Assistance?:
What type of public assistance do you receive?:
How did you hear about us:

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