Resident Housing Application

"Where Independence Meets Choice" Join Community:

We’re excited to learn more about you. Please fill out this form, and our team will reach out when housing becomes available.
Resident Housing Application

(Self Referral)
Name

First NameLast Name
Pronouns **

She/herHe/himThey/themother
Date of Birth

MonthDayYear
Date
Are you 18 years of age or older?*

YesNo
Phone Number
Please enter a valid phone number.
Email
example@example.com
Current Living Situation

HomelessStaying with FriendsRecently DischargedShelterOther
How did you hear about K&M Choice Living?

Self-referralOutreach worker / case managerFamily or friendCommunity organizationOnline search / websiteOther
Income Source

EmploymentSSISSDIRetirementOther
Are you able to provide verification of income if requested?

YesNo
Housing Preference?

Shared RoomPrivate RoomNo Preference
Expected Move-In Date?

MonthDayYear
Date
Do you require ongoing medical care, nursing services, or assistance with medications?

YesNoUnsure
I understand this is a non-medical Independent Living Facility (ILF) and residents must be able to manage their medical needs independently.*

Yes, I understand and AgreeNo, I do not agree
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship
Important Notice
K&M Choice Living is a non-medical Independent Living Facility (ILF).
Submission of this application does not guarantee housing placement.
Housing availability is based on eligibility and space.
I certify that the information provided is accurate to the best of my knowledge and I understand that submission of this application does not guarantee housing placement.*

I understand
Should be Empty:

"Where Independence Meets Choice" Join Community:

Resident Housing Application