SMALL HOME EXPERIENCE APPLICATION

1
Name
First Name
Middle Name
Last Name
2
Date of Birth
Date
Month
Day
Year
3
Gender
Male
Female
4
Email
example@example.com
5
Phone Number
6
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Why are you interested in the Small Home Experience Program?* This field is required.
8
What are your expectations of the Program?* This field is required.
9
Why should we choose you and what skills do you possess?* This field is required.
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10
What are your strengths?* This field is required.
11
What are your challenges/barriers?* This field is required.
12
GOAL 1:* This field is required.
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13
GOAL 2:* This field is required.
14
GOAL 3:* This field is required.
15
GOAL 4:* This field is required.
16
Do you have a license?
Yes
No
17
GOAL 1: * This field is required.
18
If not, are you obtaining one?* This field is required.
19
To gain employment, a state identification card, social security card and/ or birth certificate are required. Select all the documents you currently have:* This field is required.
Birth Certificate
Social Security Card
Drivers License
State Identification card
20
GOAL 2:* This field is required.
Please explain on the field provided including any food the camper is allergic to
21
Do you currently have a checking/savings account?* This field is required.
22
Have you ever created a personal budget?* This field is required.
23
How important is personal hygiene to you?* This field is required.
24
Do you have the ability to do your own laundry?* This field is required.
25
Are you currently enrolled in school or GED program?* This field is required.
26
Give brief description of clean space?* This field is required.
27
Can you cook?
28
If so, what is your favorite meal to prepare?
29
Are you easily motivated?* This field is required.
30
How do you handle stress?* This field is required.
31
Do you plan on attending college or a vocational school?
32
Do you work better as a team or individual?
33
Describe why?
34
If you find yourself in an unsafe situation, what do you do?
35
Do you currently have medical, dental, vision insurance?
36
Have you ever filled out a FAFSA, scholarship, or school loan application?
37
Do you currently use birth control or contraceptives?
38
If so, which ones?* This field is required.
39
Do you have access to a computer or laptop?* This field is required.
40
Do you have computer skills?
41
Which type of career are you interested in pursuing and what current skills do you possess that you believe will help you in that career?
42
If so, briefly describe your level of experience?
43
Do you have an email account?* This field is required.
44
Do you have a resume?* This field is required.
45
If not, are you interested in building skills to create one?* This field is required.
46
Skill: 1* This field is required.
47
Do you currently have a cell phone?* This field is required.
48
Are you currently employed?* This field is required.
49
Do you currently have a natural support system (mother, father, siblings, extended family, friends, etc.)?* This field is required.
50
If so, describe the communities you belong?* This field is required.
51
Describe the difference between building rapport and relationships?* This field is required.
52
What are you hobbies?* This field is required.
53
Are you affiliated with any groups or organizations?* This field is required.
54
Describe your affiliation.* This field is required.
55
Have you ever obtained assistance from private or state organization?* This field is required.
56
If so, describe.* This field is required.
57
Skill 2:* This field is required.
58
How familiar are you with community resources? Please name a few, what services they provide and the benefits?* This field is required.
59
Do you have access to community resources if needed?* This field is required.
60
Skill 3:* This field is required.
61
Have you ever utilized a community food bank?
62
Do you prefer to live alone or with a roommate?* This field is required.
63
How well do you get along with others?* This field is required.
64
What for of transportation do your currently utilize?* This field is required.
65
Do you know the steps necessary to become a homeowner?* This field is required.
66
Do you know how a home is financed through a mortgage?* This field is required.
67
Can you explain the home buying process in simple terms?* This field is required.
68
Do you know how property taxes work?* This field is required.
69
Do you know what a home warranty program is?* This field is required.
70
Do you know how to do landscaping?* This field is required.
71
Do you know how to repair and maintain appliances (e.g. refrigerator, washer/dryer, stove/oven, dishwasher, etc..)* This field is required.
72
Do you know how to inspect a home for major damage ( e.g. roof, ceiling , termites, water damage, HVAC system, etc.)* This field is required.
73
Would you be comfortable cleaning a house on your own?* This field is required.
74
Are you familiar with preventative fire safety measures?* This field is required.
75
Are you confident in your ability to respond to a house fire?* This field is required.
76
Would you know what to do if the electricity in your home goes out due to a power outage or other reason?* This field is required.
77
Are you confident in your domestic skills (dish washing, clothes washing, floors/rugs, bathrooms/kitchens, trash, etc.)* This field is required.
78
Do you know how to create and maintain a budget?* This field is required.
79
Have you ever managed more than $1,000, personally?* This field is required.
80
Have you ever managed more than $5,000 personally?* This field is required.
81
Have you ever been flat broke?* This field is required.
82
Are you familiar with ways to save money to earn interest?* This field is required.
83
Are you familiar with how financial investments operate?* This field is required.
84
Can you explain the difference between real estate investment and stock market investment?* This field is required.
85
Do you know what a will is?* This field is required.
86
Do you know what a trust is?* This field is required.
87
Do you understand how income tax withholding operates?* This field is required.
88
Do you have medical insurance or coverage?* This field is required.
89
If it is paid for from your job, can you explain how your employer's contribution works?* This field is required.
90
INCLUDE ALL THAT APPLY* This field is required.
DO you have a retirement plan?
Do you do activities regularly to charge your batter? (pray, meditate, walk, run, ride a bike, enjoy nature, etc.)
Have you ever been on vacation?
Do you understand the importance of regular exercise?
Do you understand thee importance of healthy eating?
Do you know what a "vision board" is?
Do you have goals?
91
Answer the following in the box below:* This field is required.If you selected one of these answers above please answer below: (1.Do you know what a vision board is? Do you have goals) Do your friends have similar goals? What has been your greatest failure in life, so far? What has been your greatest success in life so far?
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