Independent Living Waiting List Application

Independent Living Waiting List Application

Please complete this form to join the waiting list for Independent Living accommodations.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Current Living Situation
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name*
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Referral Source
Referral Date

MonthDayYear
Date
Eligibility Category

Returning Citizen (Reentry)HomelessVeteranAdult 24+Elderly (60+)Other
Current Housing Situation

ShelterHospital (Discharge Pending)Correctional Facility (Release Pending)Staying with Friends/FamilyUnshelteredOther
Expected Release Date

MonthDayYear
Date
Monthly Income Amount ($)
Income Source
Do You Have a Representative Payee?

YesNo
Employment Status

Full-TimePart-TimeUnemployedDisabled
Are you willing to follow house rules and curfew?*

YesNo
Are you able to live in shared housing?*

YesNo
Do you have any active violent charges?*

YesNo
I understand that placement in Higher Ground Living Solutions is based on eligibility, availability, and program criteria. Submission of this form does not guarantee housing placement. I certify that the information provided is true and accurate to the best of my knowledge.
Electronic Signature*
Date*

MonthDayYear
Date
Preferred Move-in Date

MonthDayYear
Date
Do you have any accessibility or special accommodation needs?

YesNo
Please provide any additional information or special requests
Should be Empty: