Associated Ministries Universal Program Application
Section 1. Household Overview
Household Size
Number Adults
Number Children
Total Household Income (for all household members 18 & over)
Section 2. Basic Information (Applicant/Head of Household)
Name
First Name
Middle Initial
Last Name
DOB
-
Month
-
Day
Year
Date
Age
Disability
Veteran Status
Gender
Health Insurance
Education Level
Primary Race
Multi-Racial
Primary Language
Pronouns
Secondary Race
Marital Status
Sexual Orientation
Ethnicity
Employment Status
Fleeing Domestic Violence
Section 3. Contact Information
Phone Number
Format: (000) 000-0000.
Phone Number Type
Email
example@example.com
Preferred Contact Method
Best Time to Contact
Additional Contact Details/Notes
Section 4. Housing Information
Housing Status
Housing Stability
Housing Type
How Long (if unknown, estimate)
Start Date (if unknown, estimate)
Mortgage/Rent Amount
Sub-Section 4a. Physical Address - If unhoused, enter the city and zip code where you stay most often.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sub-Section 4b. Mailing Address - Do you have a separate mailing address?
Yes
No
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Section 5. Monthly Income - Do you receive income from any source?
Do you receive income from any source?
Yes
No
Income Source 1
Source 1 Amount
Income Source 2
Source 2 Amount
Section 6. Emergency Contact (someone who is able to reach you if we are unable to) - Do you have an Emergency Contact?
Do you have an Emergency Contact?
Yes
No
Emergency Contact Name
Relationship
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Consents
Section 7. Referred By
How did you hear about us?
Section 8. Application Attachments Included
Additional Household Member Appendix
Program Supplement
Program Disclosures
Other
Other
None
901 S 13TH ST, TACOMA WA 98405 • 253-383-3056 • www.associatedministries.org
Initials:
Universal Program Application-Form 001 (Online)-Ver.2 03/08/2026
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Supplement to AM Universal Program Application AHS Home Provider - Property Information and Matching Criteria
Supplement Section 1. Property Information
Do you live on the property?
Property/Housing Type
Mortgage/Rent Amount
Relationship to Property
If Renting, Owner/Landlord Name
Owner/Landlord Phone or Email
Supplement Section 1a. Room/Unit Rental Information
Number of Rooms Available to Rent
Furnished or Unfurnished Unit(s)
Desired Monthly Rental Amount
Supplement Section 1b. Property Address
Property Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supplement Section 2. General Matching Criteria
Is Smoking Allowed?
Is Drinking Allowed?
Are Pets Allowed?
If Yes, List Allowable Pets
Disclosures and Acknowledgements:
Full text of the disclosures listed below are provided on page 3 of this application. Please read all disclosures and acknowledge understanding of each below: I have read and understand each of the following disclosures:
Criminal History Policy
Agreement of Non-Liability
Program Exit Guidelines
Associated Ministries Release of Information (general)
Completed Application Packet
Nondiscrimination Disclosure
True and Accurate Information:
I certify the information I have provided in this application is true and accurate to the best of my knowledge.
Signature
Date
-
Month
-
Day
Year
Date
901 S 13TH ST, TACOMA WA 98405 • 253-383-3056 • www.associatedministries.org
Initials:
Universal Program Application-Form 001 (Online)-Ver.2 03/08/2026
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Adult Homeshare Program Disclosures
Criminal History Policy
As a social service agency, we value safety and well-being of our clients, employees, and volunteers. It is therefore the policy of Associated Ministries to carefully screen all applicants for any criminal charges, arrests, convictions, and warrants. Applicants are screened through the Washington State Patrol.
Based on information received by Associated Ministries through a completed background check, it is our policy not to refer any applicant to the Adult Home Share Program who has been charged, arrested, or convicted of the following crimes within the last ten years: felonies, thefts, domestic violence, crimes of child or elder abuse, and any actions involving destruction of property or physical violence toward persons. Additionally, any active warrants will also serve as grounds for denial of participation from the program, regardless of how old the warrant is. Applicants must resolve all active warrants and go through the appeal process in order to be reconsidered for participation. Clients who possess a criminal history that features sexual crimes, murder, or voluntary manslaughter within their lifetime will be automatically disqualified and unable to request an appeal.
Upon receipt of an adverse criminal history report, the applicant will be sent a letter denying their application due to relevant criminal history. It will state which crimes fall under the policy criteria as well as procedures to follow if the client wishes to seek review/reconsideration through the appeal process. The client is allowed a period of two months to schedule a criminal appeal appointment. If the client fails to do so within this timeframe, they will not be able to reapply for entrance into the program for the next two years.
Policy on nondiscrimination: All services offered by Associated Ministries are provided in a manner which is free from discrimination on the basis of race, color, religion, sex, sexual orientation (gender identity/expression), national origin, age, handicap, and familial status.
Agreement of Non-Liability
I understand that the staff of Associated Ministries will use their facilities to bring together those who have available housing (homeowner's) with those who express a desire for housing (home seeker's).
I, as a home seeker, understand that Associated Ministries is not the agent of either party, but acts only as a facilitator, to provide the opportunity for the parties involved to come together and work out an acceptable housing agreement.
I am not relying entirely on Associated Ministries as to condition of the premises and their suitability for my needs. I agree to obtain and/or confirm information myself.
Any disputes between the homeowner and home seeker which may arise shall not involve the staff of Associated Ministries, either individually or as a group, and I will not hold staff responsible for any claims, damages, or other consequences which may arise from any home sharing arrangement.
I have also been advised to seek the services of an attorney should I have any questions about my legal rights and the laws of the State of Washington.
Program Exit Guidelines
Associated Ministries is a non-discriminatory, equal opportunity Non-Profit, shared housing agency. We strive to serve Tacoma, larger Pierce County, and South King County, regardless of gender, age, race, religion, sexual preference (gender identity/expression), or socio-economic status. As part of the program, Associated Ministries requires everyone to provide copies of photo identification, Social Security card, and proof of income. In addition to this, all applicants must pass a criminal background check based on the agency's criminal history policy. If a person is having trouble meeting any of these requirements, he or she should talk with staff to discuss alternatives.
Below is a list of reasons a participant may no longer receive services and be exited from the program:
1. Falsifying information
2. Disrespectful to staff in person, on the phone, or in writing
3. Disrespectful behavior toward another home sharer or home provider
4. Damage done to Associated Ministries property, the property of a home provider, or the property of a home seeker
5. Inappropriate behavior or boundaries toward staff or a program participant
6. Crimes or illegal activity committed while in the program
7. Non-compliance with substance abuse or mental health treatment
8. Lack of contact by a non-matched program participant by phone, email, and mail after 2 months
9. Failure to comply with services or rent contractually agreed upon by the home seeker and home provider
10. Failure to comply with Washington State landlord/tenant laws
11. If the home becomes uninhabitable or not fit for home sharing
Staff exercises their right to exit anyone from the program if they fall into one of the above listed categories. The list is not comprehensive and someone may be asked to leave for another reason. In addition, staff may use discretion at anytime and allow a participant to stay in the program based on the nature of the offense.
Associated Ministries Release of Information (general)
I hereby authorize Associated Ministries staff to send information to and discuss my personal circumstances with coordinators and staff of other agencies.
It is understood that any interchange of information made between staff and coordinators of Associated Ministries and other agencies will be used only for purposes of attempting to determine appropriate services on my and my family's behalf.
I also authorize Associated Ministries staff to provide information supplied by myself and information on any arrest and/or criminal convictions obtained by Associated Ministries to potential home sharers in the process of attempting to bring about a home sharing arrangement on my behalf.
Completed Application Packet
Upon submission of this application a staff member of Associated Ministries will contact me via phone within 5 business days to set up a scheduled time to submit documentation.
I understand that my application will not be complete until I submit necessary identification and income verification in person to Associated Ministries staff.
901 S 13TH ST, TACOMA WA 98405 • 253-383-3056 • www.associatedministries.org
Initials:
Universal Program Application-Form 001 (Online)-Ver.2 03/08/2026
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ASSOCIATED MINISTRIES
Appendix to AM Universal Program Application Additional Household Members
Appendix Section 1. Additional Household Members - Basic Information and Income
Appendix Section 1a. Household Member 2
Full Name
DOB
-
Month
-
Day
Year
Date
Age
SSN
Gender
Disability
Veteran Status
Primary Race
Health Insurance
Education Level
Multi-Racial
Marital Status
Pronouns
Secondary Race
Primary Language
Sexual Orientation
Ethnicity
Employment Status
Relationship to Head of Household
Monthly Income
No income from any source
Income Source 1
Source 1 Amount
Income Source 2
Source 2 Amount
Appendix Section 1b. Household Member 3
Full Name
DOB
-
Month
-
Day
Year
Date
Age
SSN
Gender
Disability
Veteran Status
Primary Race
Health Insurance
Education Level
Multi-Racial
Marital Status
Pronouns
Secondary Race
Primary Language
Sexual Orientation
Ethnicity
Employment Status
Relationship to Head of Household
Monthly Income
No income from any source
Income Source 1
Source 1 Amount
Income Source 2
Source 2 Amount
Appendix Section 1c. Household Member 4
Full Name
DOB
-
Month
-
Day
Year
Date
Age
SSN
Gender
Disability
Veteran Status
Primary Race
Health Insurance
Education Level
Multi-Racial
Marital Status
Pronouns
Secondary Race
Primary Language
Sexual Orientation
Ethnicity
Employment Status
Relationship to Head of Household
Monthly Income
No income from any source
Income Source 1
Source 1 Amount
Income Source 2
Source 2 Amount
901 S 13TH ST, TACOMA WA 98405 • 253-383-3056 • www.associatedministries.org
Initials:
Universal Program Application-Form 001 (Online)-Ver.2 03/08/2026
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