Risingphoenixhouse Residence Application

Rising Phoenix House Application Form

Please Fill Out the Form Below to Submit Your interest in Obtaining Residence at the Home
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number
Ethnic Identity
Birth Date*

MonthDayYear
Date
Marital Status
Are you a Veteran?*

YesNo
Do you have an ID Card?*

YesNo
Do you have an SS Card?

YesNo

INCOME

	Work	Housing Voucher	SSI	SSDI
Enter approximate monthly dollar amount you are receiving for work and housing. Indicate if have SS

HEALTHCARE

	Medicare	Other (Describe)
Select choice for each

MEDICATIONS: Please list all medications being used and their purpose. Click Add Medication button for each one. (enter NONE if no medications being used)*
Housing
Have you ever lost housing (please describe your situation)*
Do you have any debt?*
Describe if Yes
Other?
Incarceration or Arrests

If Yes, provide requested information in the two tables that follow
Do you have any past, current, or pending charges? If Yes, provide requested information in the the tables below*

YesNo

Enter information for each criminal offense you have been charged with.

	Date of Occurrence	Docket Number	Description	Outcome
Charge 1
Charge 2
Charge 3
Charge 4
Charge 5

Provide Case Manager (CM) or Parole Officer (PO) contact Information for each charge listed in the above table.

	Name	Phone #	Email	CM or PO
Charge 1
Charge 2
Charge 3
Charge 4
Charge 5

Work History
What work are you doing, have done, or looking for?*
What training or school are you undertaking or planning? What type?
What are your goals and plans?*
Consent to Procedures and Access to Medical Records
Rising Phoenix House requires random substance abuse testing in the house as a condition of entry to the house and remaining in the housing program. We do not require access to medical information unless you experience a medical emergency in the house or you are on medication prescribed by a physician, or on medically assisted treatment for addiction.

Please type in your name following each condition of participation in the housing program to acknowledge you have read them and to signify your consent. We ask for your signature at the end of the application.
I consent to random substance abuse testing*

First NameLast Name
I Consent to the following regarding Access to Medical Records and other personal information: The Participant hereby allows physicians, psychiatrists, and other providers of healthcare (including hospitals) who have treated the Participant, to release to Rising Phoenix House, information needed for necessary medically assisted treatment while in the supportive house. With respect to the Rising Phoenix House only, the Participant hereby releases al privileges attached to the physician/patient relationship and to any communication, verbal or written, arising out of such a relationship. The Rising Phoenix House is authorized to request, receive, and review any information, verbal or written, pertaining to the Participant's physical or mental health, including hospital medical records, and to execute any releases, waivers, or other documents that may be required in order to obtain such information, and may disclose such information to such persons, organizations, and healthcare providers as the Rising Phoenix House may designate.*

First NameLast Name
Consent to Photography
I, the undersigned, of legal age, hereby irrevocably grant to Rising Phoenix House (www.RisingPhoenixHouse.org) its subsidiaries, affiliates, agents, licensees, successors and assigns thereof (hereinafter referred to as “Company”), claiming under or through same, the following rights to use the materials and/or items described herein in any fashion, form, or media, whether currently in existence or hereinafter devised:1. The right to photograph, record, videotape, store, and use the undersigned’s name, voice, appearance, likeness, signature and/or written testimony or statement along with any material furnished by me, in whole or in part, in any training, training materials and/or advertising materials produced, used or provided by Company, its subsidiaries, affiliates, agents, licensees, successors and assigns thereof, through means of mass, digital, and/or electronic media, including but not limited to printed, radio and television, promotional materials or events, and/or marketing plan, the Internet, and any other media and for all other types of advertising, publicity, promotion and other trade purposes for Company, its products and services; 2) The right to publish, text, exhibit, distribute and use the written or recorded testimonial or statement, or any parts thereof, my likeness and image, which shall appear as follows: first name and surname, general location of residence, and, where applicable, accompanied by photographs and/or recordings and/or signature, for commercial and/or non-commercial purposes, including but not limited to the advertising or solicitation of purchases, anywhere in the world where Company conducts business or intends to conduct business. I, the undersigned, hereby grant Company full ownership of and complete interest in any copyright I may have with regard to any written statement or other tangibly-fixed expression, which I have provided. I, the undersigned, hereby release and agree to indemnify and hold harmless Company, its subsidiaries, affiliates, officers, directors, agents, owners, employees, successors and assigns thereof, from any and all claims, actions, causes of action, damages, expenses, courts costs, attorney fees, liability damage or judgment suffered by the undersigned regarding the undersigned’s participation in or testimonial furnished by the undersigned to Company. I, the undersigned, hereby acknowledge that I have not been paid or otherwise compensated for the rights granted above. I further certify that all material, whether verbal, written or exhibited by me is not scripted or coached and represents my individual opinions and beliefs, and are true and correct to the best of the my knowledge. I, the undersigned, hereby acknowledge that I have read this document and understand its contents. I further acknowledge that I have executed this document voluntarily
Type in your name for consent to Photography*

First NameLast Name
Consent to Background Check
By typing my name below and signing this form for submission, I hereby authorize Rising Phoenix House and/or its agents to make investigation of my background, references, character, past employment, consumer reports, education, and criminal history record information which may be in any state or local files, including those maintained by both public and private organizations, and all public records, for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to the acceptance of my application for housing.
Type in your name for consent to Background Check*

First NameLast Name
Case Management

Please list agencies and persons currently working with you.
Name of Agency #1
Agency
Agency #1 Representative
Enter First & Last Name
Email (Agency #1)
example@example.com
Phone Number (Agency #1)
Please enter a valid phone number.
Describe support being provided to you by Agency #1
Name of Agency #2
Agency
Agency #2 Representative
Enter First & Last Name
Email (Agency #2)
example@example.com
Phone Number (Agency #2)
Please enter a valid phone number.
Describe support being provided to you by Agency #2
Emergency Contacts (Family or Friends)
Name

First NameLast Name
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Emergency Contact
Name

First NameLast Name
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Anything else we should know about you?
UNLESS you indicate below that you do NOT want to receive a copy.*

NO, I DO NOT want a copy of my housing application to be sent to the email address I entered in the personal information section at the top of the application.
You will automatically be emailed a copy of your housing application submission to the email address entered at the top of the form. Agency representatives generally want to review your application and will be emailed a copy to email addresses entered in the Case Management section UNLESS you indicate below that you do NOT want them to receive a copy.*

NO, I DO NOT want a copy of my housing application to be emailed to the Agency Representatives listed in the Case Management section.
Please type in your name then sign the form below*

First NameLast Name
By typing my name and adding my signature, I attest that my application has been completed to the best of my knowledge and consent to substance abuse testing procedures, access to medical records, photography, and background checks. I understand that any false answers or statements, or misrepresentations by omission, made by me on this application or any related document, may be sufficient for rejection of my application or for my immediate discontinuance should such falsifications or misrepresentations be discovered after I am accepted for the Rising Phoenix House program.*

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Date of signature*

MonthDayYear
Date
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Rising Phoenix House Application Form

Housing

Incarceration or Arrests

Work History

Consent to Procedures and Access to Medical Records

Consent to Photography

Consent to Background Check

Case Management

Emergency Contacts (Family or Friends)

Additional Emergency Contact