The Lake County Haven
Online Client Application

Dear Haven Applicant:

Below is the Lake County Haven application. Upon completion of the form, the results will be sent in a secure email to our staff for review. If you have any questions, please call us at 847-680-5408.

Before you continue, please consider the following:

• Women and children are expected to be open and honest in all relationships with members of LCH
  community
• Women and children are expected to behave with respect for self, others and property
• The use or possession of alcohol or drugs on or off shelter property is prohibited
• Residents are expected to concentrate on their own issues and concerns, rather than those of other
  residents

Sincerely,
The Lake County Haven

Personal Information

First Name Last Name Street Address City State Zip Telephone Date of Birth Referred By

Family Information

Marital Status Child's Name (if applicable) Child's Age Child's Residential Parent Will Child Reside in Our Shelter? No Yes