Women's House & Men's House Residency Application

Women's House & Men's House Residency Application

Please set aside 20-30 minutes to fill out the application. Ensure you have all necessary information gathered prior to filling out the application as it does not allow you to save and return at a later time.
Which house are you applying for?*
Personal Information
Name*

First Name Last Name
E-mail*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Age*
Birthdate*

MonthDayYear
Date
Height*
Weight*
Primary Language*
Ethnicity*
Are you a legal resident of the United States?*

Education
Highest level of education COMPLETED?*
Make sure you are clicking on the grade that you completed/finished.
Do your future plans include completing any of the following? (Select all that apply.)*

GEDHigh SchoolVocational TrainingCollege DegreeNone of the above
If applicable, what is your desired field of study?
Do you have any learning disadvantages/disabilities?*

Family History & Relationships

Please describe your relationship with your family members below:
Father:*
Mother:*
Siblings:*
Dependent Children:*
Extended Family/ Additional Support Persons:*

Physical Health
Do you have any existing medical conditions?*
Are you taking any prescribed or over the counter medications? If yes, please describe what they are for.*
Do you think you may be pregnant? If yes, have you been tested?*
When was your last dental exam? Do you currently have any issues?*
When was your last eye exam? Do you currently have any issues?*
Do you use tobacco or vape?*

YesNo

Have you ever had/have an STD/STI or any other communicable disease?

YesNo
If yes, please provide type of communicable disease and date diagnosed
Please list medication for communicable disease
References

List three references who are aware of your situation and could verify your need and willingness to work the program through JRO. Please provide their relationship to you (Ex. Family member, lawyer, caseworker, advocate, friend, teacher, etc.)
Reference #1
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
How long has he/she known you? Relationship?
Reference #2
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
How long has he/she known you? Relationship?
Reference #3
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
How long has he/she known you? Relationship?

Comments & Signature
How did you learn about this program?*
If agency, what is the name of the organization?*
What is it about this program that makes you think it might be a good place for you?*
Is there anything else you would like us to know or consider about you regarding your application?*
By signing below, I understand an application is not a guarantee of admission to Blake's House or His House. I understand my eligibility will be based on the availability of the space in the home. If accepted, I understand that I must sign the member handbook and other documents outlining the terms for living at Blake's House or His House to uphold my safety and the safety of the other residents. I understand my references will be contacted to verify the honesty of my statements. If my statements are found to be falsely represented at any point, or I have demonstrated an unwillingness to work within the expectations and terms of my admission, I may be exited from Blake's House or His House immediately. By signing, I also permit Blake's House and His House to request official documents, make professional inquiries and complete a background check to verify the information provided. Lastly, I understand that Blake's House and His House hold the right not to disclose the rationale for the denial of admission.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Personal Information