Blake's House & His House Residency Application

Blake's House & His 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
Select Highest Education Level*
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?*
Are you having any issues with your teeth right now? If yes, what?*
When was your last eye exam?*
Are you having any issues with your eyes? If yes, what?*
Do you use tobacco or vape?*

YesNo

References

List three references who are aware of your situation and could verify your need and willingness to work the program through JRO.
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?
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?
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?

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