Centre for Youth Care Inc.
Supporting Youth Since 1971
SUPPORTIVE HOUSING APPLICATION
Name
First Name
Last Name
Gender
Pronouns
Date of Birth
/
Month
/
Day
Year
Date
Language
Social Insurance Number
Current address
Phone Number
Current Living Situation? Friends/family/shelter/rooming house etc.
Are you currently receiving YES assistance?
Who referred you to this program?
Do you have one adult that is and will be a support person if you are accepted? *If so, please provide details
Centre for Youth Care INC.
Most recent or current school
Highest grade completed
Are you currently employed?
Any information you feel it is important for us to know about your education and/or employment?
Do you have any physical health concerns?
Do you have any mental health concerns/diagnosis?
Medications
Do you have a Medicare Card?
Any information you feel it is important for us to know about your physical and/or mental health?
Doctor
Centre for Youth Care INC.
Tell us why you think you would be a good fit for the Supportive Housing Program
List 3 positive personality traits
List 3 things you are proud of
List 3 interests or hobbies
Submit
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