College Admissions Form

Self-Sufficiency Program Pre-Admission Form

Enter your information below. Once we receive this form from you, someone will follow up with you within 3-4 business days.
Applicant Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Race/Ethnicity*
Gender*

MaleFemale
Phone*
E-mail Address*
example@example.com
Which Self-Sufficiency Program are you applying for?*
Address (If you are homeless, type "Homeless" for street address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If homeless, how long have you been homeless?*
Household Composition
How many people are in your household?*
How many adults?*
How many children?*
How many college students*
Is anyone in your household disabled?*

YesNo
If yes, who is disabled in your household?
Select all that apply.
Household Income
Does your household have income?*

YesNo
If yes, who in your household has income?*
Select all that apply.
Sources of income?*
Select all sources of income.
What is your household's annual income?*
Household History
Have you ever been a client of Lazarus House Initiative, Inc. before?*

YesNo
If yes, how long ago?*
Does anyone has a history of alcohol or drug abuse/addiction?*

YesNo
If yes, how long has it been since the last use?*
Number of Alcohol or Drug Treatments?*
Sobriety Date?*
Are you working a 12-step program?*

YesNo
Do you have a sponsor?*

YesNo
Did anyone 12 years old or older quit school before graduating?*

YesNo
Who quit school before graduating?*
Has any anyone 18 years old or older ever had a Pell Grant?*

YesNo
Who has had a Pell Grant?*
Has any anyone 18 years old or older ever had a Student Loan?*

YesNo
Who has had a Student Loan?*
Has anyone 18 years old or older defaulted on a Student Loan?*

YesNo
Who has defaulted on a Student Loan?*
How long has it been since the default happened?*
What caused the Student Loan Default*
Has the applicant or head of the household ever lived independently in her/his own apartment, duplex, town home, condominium, or house?*

YesNo
How long?*
Has the applicant, head of the household, or anyone 18 years old or older in the household ever been evicted?*

YesNo
How long ago?*
Has the applicant, head of the household, or anyone 18 years old or older in the household ever been convicted for violent or drug related criminal activity within the past 5 years?*

YesNo
Is the applicant, head of the household, or anyone 18 years old or older in the household awaiting trial for any criminal activity?*

YesNo
When/Explain *** Note household members with convictions for producing methamphetamine or registered sex offenders will be denied.
Do all adults in the household have goals they want to accomplish while in the program?*

YesNo
Provide the name(s) and goals each adult wants to accomplish while in the program, if accepted.
Please rate your experience with completing this form.

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1 is Worst, 5 is Best
Name

First NameLast Name
Date

MonthDayYear
Date

Self-Sufficiency Program Pre-Admission Form

Household Composition

Household Income

Household History