Language
English (US)
Application for Residency
Please answer all of the following information to apply for residency at Marguerite's Place. Some questions are required by our funders, however all of your personal information will be kept anonymous.
Applicant Information
Date of Application:
*
Name:
*
First Name
Last Name
Email:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Is it safe for staff to leave you a voicemail?
*
Please Select
Yes
No
Which most accurately describes your race?
*
Black/African American
White/Caucasian
American Indian or Alaska Native
Asian
Native Hawaiian and Other Pacific Islander
Other
Do you identify as Hispanic or Latino?
*
Please Select
Yes
No
Primary Language:
*
Applicant age:
*
Date of Birth:
*
Social Security Number:
*
Referred by:
*
Family Information
Children Information
*
Name
Date of Birth
Age
Gender
Custody
(Full/Share/None)
Social Security Number
Child 1
Child 2
Child 3
Child 4
Do you have a parenting plan in place?
*
Please Select
Yes
No
N/A
Have your children ever been enrolled in childcare?
*
Please Select
Yes
No
Are your children currently enrolled in childcare?
*
Please Select
Yes
No
Have your children ever witnessed or experienced abuse?
*
Please Select
Yes
No
Unsure
Do you have any particular concerns about your children's development? If yes, please elaborate:
*
Are you currently pregnant?
*
Please Select
Yes
No
Unsure
Income Information
Are you authorized to work in the US?
*
Please Select
Yes
No
Are you currently working?
*
Please Select
Yes
No
If yes, where?
What are your income sources? Check all that apply.
*
Employment
TANF
Child Support
Food Stamps
SSI
SSDI
Worker's Comp
Alimony
Unemployment
APTD
Other
Are you eligible for TANF?
*
Please Select
Yes
No
Unsure
If currently receiving TANF, are you under a medical exemption?
Please Select
Yes
No
What is your monthly income?
*
Personal Information
Where are you currently living?
*
Have you ever lived in a Transitional Living Program or Housing Program?
*
Please Select
Yes
No
If yes, please list programs and length of stay:
Program Name
Length of Stay
Program Name
Program Name
Program Name
Do you have a history of substance use?
*
Please Select
Yes
No
If yes, what is your length of sobriety?
Have you ever been convicted of a crime?
*
Please Select
Yes
No
If yes, what was the conviction?
At any point in your life, have you experienced or witnessed violence?
*
Please Select
Yes
No
Have you struggled with mental health challenges in the past?
*
Please Select
Yes
No
If yes, have you engaged with any supports such as counseling or a support group?
Please Select
Yes
No
Is there anything else you would like us to know as part of this application?
Thank you for applying for housing with Marguerite's Place.
Staff of Marguerite's Place will contact you to confirm receipt of this application. We keep a waitlist for our apartments and will process applications in order of receipt when an apartment becomes available. If you have any questions about the status of your application, please contact Director of Residential Services Patti Joseph at pjoseph@margueritesplace.org or 603-598-1582 x 12.
Submit Application
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