SIL Applicant
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Number where you can be reached.
Format: (000) 000-0000.
Email
*
example@example.com
SIL Locations Preferred.
Fort Worth
Dallas
Crowley
Move In Date
*
Are you 18 or older?
*
Yes
No
What is your gender?
*
Male
Female
What is your sexual orientation?
*
Straight
Bisexual
Lesbian
Gay
How do you feel about having a roommate?
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I am able to follow chore schedule and keep house clean without supervision.
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I know how to respect other boundaries and choices.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I get upset easily.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
Have you ever destroyed any property?
*
Yes
No
Have you ever had an sexual allegations against you?
*
Yes
No
Are you currently enrolled into school or have a job?
*
I am currently enrolled into school
I am Employed
No
I am currently seeking Employment/Education
Do you have any pending criminal charges?
*
Yes
No
Do you have any medical diganoised conditions?
*
Yes
No
I Do Not Know
Are you currently taking an Meds?
*
Yes
No
Do you use or have you ever used illegal drugs?
*
Yes
Occasionally
Experiment
No I never use drugs.
I like to consume Alcohol Beverages.
*
Yes
Occasionally
Just Depends
No I never had a alcohol beverage
I take things that does not belong to me.
*
Strongly Agree
Agree
Sometimes
Disagree
Strongly Disagree
I am only applying for SIL because I have no other choice.
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Once accepted into SIL Program, if for any reason contract and rules are broken and I am asked to leave, depending on severity of situation, I will leave same day if asked, or by the timeframe given by the Director.
*
I Agree
I Do Not Agree
Open for Discussion
Are you willing to participate in programs and activities provided by the SIL provider including life skills?
*
Yes
No
Visitors, Alcohol, Drugs are Prohibited and a standard curfew is given with approved exceptions. Failure to comply may result in immediate eviction.
*
I Agree
I Do Not Agree
I have reviewed Valuing Other Lives website, and received all the information pertaining to SIL Program and other services that are provided.
*
I was able to review website
I did not review webiste.
I have questions regarding website.
Request Move in Date
Signature
Continue
Continue
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