Shared Living Waiting List Application

Thank you for your interest in the Successful Solutions Shared Living Program. Please provide us with some information to help us better understand your shared living needs.

The Wait List Application helps you to understand that the Successful Solutions Shared Living Program is a membership arrangement. At the end of reviewing the information, we ask you to let us know if you have determined the Shared Living Program is the right fit for you or your clients.

As you are probably aware, the need for affordable housing is extremely necessary and getting harder to find. Help us to help you and others out there in need of help as well.

The questions we ask on this wait list application help us to get a better understanding of what future housing programs we need to look into providing in Fort Pierce and the Treasure Coast.

If you have question about something asked or not asked please contact us.

WE ARE HERE FOR YOU!

First and Last Name:*

Date of Birth:*

Phone Number*

Area CodePhone Number

Email Address*

example@example.com

How did you hear about us*

Where are you currently living?:*

Why are you looking for housing right now?:*

How soon are you wanting to join the Shared Living Housing Program?:*

Admission Placement is based on availability and having met the membership requirements.

Length Of Stay:*

Admission Placement is based on availability and having met the membership requirements.

Payment / Income Source:*

Members must provide proof of income!

Are you currently employed?*

YesNo

Name of Employer and Hours of employment if applicable:*

If not employed put: NONE

IF employed please provide the name of the employer. *

If not employed put: NONE

Are you receiving assistance from an organization, hospital, or caseworker?*

YesNo

Name of organization/ caseworker name and contact information, if applicable:*

If not applicable put: NONE

Do you have any pets?*

YesNo

Do you smoke?*

YesNo

Do you have any history of violence or unsafe behavior?*

YesNo

Do you have a vehicle?*

YesNo

Shared Living Membership Location Preference:*

Selections are based on preference availability. Admission Placement is based on availability and having met the membership requirements.

Membership Community Preference*

Preferences are based on Availability. Admission Placement is based on availability and having met the membership requirements.

3 References*

	First Name	Last Name	Phone Number	Years Known
1
2
3

Shared Living Preference:*

Private Room & Single-Family Membership Rate are offered at increased member fee. Admission Placement is based on availability and having met the membership requirements.

I understand that this application for membership with Successful Solutions Shared Living is a membership agreement, and not a lease or tenancy. If approved, I will become a paid member of, Successful Solutions Shared Living Program, holding a license to occupy, which can be revoked if the membership residential rules are not followed and if membership dues are not received on time on or before the due date. – I understand that there is a $300 one-time non-refundable administrative member enrollment fee. This fee reserves the new members' availability for a room assignment placement and covers the cost of pre/ post, shared living preparation and house maintenance expenses.*

I have read and understand these terms.

- Successful Solutions Shared Living Program Rooms are filled as they become available to members that have completed the member requirements for enrollment into the program: - I understand all membership plans are month-to-month!- I understand that the membership dues specified room rate is to be paid at the time of move-in and on the 10th day of each month thereafter. – I understand that the member enrollment fee is not a security deposit and is non-refundable. - I understand that there is no move-in deposit required, only the selected room rate outlined in the member's intake room agreement – I understand Membership Minimum Age 18– I understand the membership properties do not allow pets*

I have read and understand these terms.

- I understand that the Shared Living Program houses are fully furnished, and I will not be bringing any unauthorized furniture into the residence for storage- I understand that all members are required to have a PO BOX or alternate mailing address. This is a memberhip shared housing program offering short or long-term shared living, not a rental arrangement.– I understand that there is absolutely "NO SMOKING OF ANY KIND ALLOWED INSIDE" the residential properties. Smoking is allowed only in designated smoke areas outside of the home. - I understand that these are drug and alcohol-free shared living residences. I understand that these are Zero Tolerance of Violence shared living residences. (If any of this is going to be an issue, look for other shared living options)*

I have read and understand these terms.

- I understand that the Successful Solutions shared living programs with rules, limitations and restrictions must be followed. -I understand and will respect other member residents in the shared living residence that may be members of differing ethnicities, genders, races, religions, and sexual orientations, than that of myself. - I understand that if approved for the Successful Solutions shared living program, that I will be expected to attend and participate at least once monthly in one of the residential support services programs available to shared living members.*

I have read and understand these terms.

Let us know if you are interested in scheduling an intake to become a member of the Successful Solutions Shared Living Program?*

Emergency Contact*

	First Name	Last Name	Phone Number	Relationship
Contact 1
Contact 2

Signature*

Date*

Date

ALL DONE! PLEASE SUBMIT!

Our office will contact you within 1-2 business days.

Shared Living Program Wait List Application

Waiting List Preliminary Membership Agreement Terms!