Community Housing Project Registration Form

Basic Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Where were you referred from?

Income & Benefits
Do you have a steady source of income?

YesNo
Do you receive food stamps/EBT?

YesNo
Do you have a working phone we can use to contact you?

YesNo

Heading
Are you able to live independently without daily assistance?

YesNo
Do you currently receive help with daily activities?

YesNo
Do you currently have trouble accessing your medications?

YesNo
Are you currently taking prescribed medications?

YesNo

Housing Preferences & Needs
What type of room are you looking for?

Shared RoomPrivate RoomNo Preference
When do you need housing?
Do you understand this is a shared independent living program and you will have a roommate?

YesNo
Do you have any physical disabilities or mobility concerns?

YesNo

Background Screening
Have you ever been evicted from a previous residence?

YesNo
Have you ever been convicted of a felony?

YesNo
Are you a registered sex offender?

YesNo

Lifestyle & House Rules
Are you willing to follow house rules?

YesNo
Do you smoke?

YesNo
Do you have any pets?

YesNo

Final Notes
Why are you seeking housing at this time?
Is there anything else you would like us to know?
Should be Empty: