Statement of Interest

Statement of Interest

Thank you for filling out the form below. Someone from Solon Community Living will be in contact with you shortly after submission.
Primary Contact Name*

First NameLast Name
E-mail*
example@example.com
Primary Contact Phone Number*
Preferred Method of Contact*

PhoneTextEmail
Potential Resident Information

All information beyond this point is regarding the potential future resident of Solon Community Living.
Potential Resident Name*

First NameLast Name
Date of Birth:

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you presently receiving waiver services?*

YesNoI Don't Know
Do you have an assigned SSA (Service and Support Administrator) from your county board?*

YesNo
Where do you presently live?*

Home with familyIndependentlyCongregate setting (i.e. Group Home)Other
Do you have a legal guardian?*

YesNo
When are you looking to move?*

One YearTwo YearsMore than two years
How did you hear about Solon Community Living?
Additional Comments:
Please note: This is not an application for Solon Community Living.
Should be Empty: