Join the Wise Legacy Community: Prescreen/Waitlist form We’re excited to learn more about you. Please fill out this form, and our team will reach out when housing becomes available.
Are you requesting housing for someone other than yourself? If So Please complete part 2
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Yes
No
Applicant Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Age
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Social Security Number
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***-**-****
Gender
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Male
Female
Other
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Preferred Move-in Date
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-
Month
-
Day
Year
Date
Preferred room
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Shared Room
Private Room
Anything Available
Location Preference:
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Canton
Income Source:
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SSI
SSDI
Retirement
Employment (Job)
Other
Monthly Income amount?
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$$$
Would you be able to provide proof of income?
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Yes
No
Payment Plan for Rent?
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Monthly
Bi-weekly
Weekly
Support Needed:
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SNAP/Medicaid
ID Help
Job Readiness
Please select any that apply to your current situation:
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Veteran
Returning Citizen (Formley incarcerated)
Currently experiencing homelessness or housing instability
Survivor of Domestic violence
Low Income or Fixed Income
Adged from Foster care
Student
Other
Do you understand that Wise Legacy Residential is a Shared living program, and that by entering this housing environment you are agreeing to participate in a structured, supportive setting designed to help build stability, independence, and healthy routines?
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Yes, I Understand
No, I Don't Understand
I Have Questions
Any history of sex- offender registration or violent charges? (This does not disqualify you)
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Yes
No
Please tell us a little about yourself, any medical, mobility, personal needs or support you may require, and why you’re interested in joining Wise Legacy Residential:
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Referral Source/ How did you hear about us?
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ex. Agency, Existing Resident etc
Signature (Confirm Accuracy and understanding)
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Part 2 Completing form for someone else?
Please Complete Below
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to person Applying
Family
Friend
Agency
Social Worker
Other
Referral Agency/Source
Please describe any information you think we would need. Thank you for your help completing this form. We appreciate you!
Thank you for your interest in Wise Legacy Residential. We appreciate you reaching out to join our community. A member of our team will follow up with you when a space becomes available or if any additional information is needed to move forward
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