Participant Intake Form
Please provide the following information to participate in the program.
Disclaimer: We don’t provide medical care or assistance with daily living. Participants must be independent.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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of
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Other
Which applies to you?
Veteran
Senior
Disabled Adult needing affordable housing
Do you have a steady income?
*
Yes
No
Estimated Monthly Income
*
Do you receive SNAP benefits?
*
Yes
No
Can you live independently without daily assistance?
*
Yes
No
If you receive help with daily activities, please explain.
Medical/Mental History (allergies, conditions)
*
Are you taking any prescribed medications?
*
Yes
No
Medication Information
When do you need housing? (Move-in date)
*
-
Month
-
Day
Year
Date
Do you smoke?
*
Yes
No
Are you willing to follow house rules?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Do you have pets?
*
Yes
No
Why are you seeking housing?
*
Submit
Should be Empty: