HOUSING PROGRAM MEMBERSHIP INTAKE ASSESSMENT
Please answer all questions truthfully. No specific answer will disqualify you.
I understand that this application is for a membership in an independent co-living housing program. I can manage my daily activities without physical assistance. I understand that no personal care or assisted living services are provided with monthly fees.
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I understand the above statement
REFERRAL AGENCY
shelter, agency or hospital name
NAME OF REFERRER
name of person you spoke with at the above shelter, agency or hospital
YOUR NAME:
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First Name
Middle Name
Last Name
Suffix
CURRENT LIVING SITUATION:
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HOMELESS SHELTER
GROUP HOME
NURSING HOME
PARENTS
GRANDPARENTS
SISTER
BROTHER
FRIEND
Other
CURRENT ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
LAST 4 OF SSN:
BEST PHONE NUMBER TO REACH YOU:
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Area Code
Phone Number
EMAIL ADDRESS:
DATE OF BIRTH:
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-
Month
-
Day
Year
Date
AGE:
GENDER:
PRIMARY LANGUAGE:
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ENGLISH
SPANISH
Other
MARITAL STATUS:
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MARRIED
SINGLE
DIVORCED
WIDOWED
EMPLOYMENT STATUS:
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EMPLOYED
SEEKING EMPLOYMENT
NOT SEEKING EMPLOYMENT
Other
EMPLOYER:
enter N/A if this doesn't apply
EMPLOYER ADDRESS:
enter N/A if this doesn't apply
HOW MANY HOURS DO YOU WORK PER WEEK?
enter N/A if this doesn't apply
WHICH DAYS OF THE WEEK DO YOU TYPICALLY WORK?
ex: M-F or enter N/A if this doesn't apply
WHAT ARE YOUR NORMAL WORKING HOURS?
ex: 9am-5pm or enter N/A if this doesn't apply
MONTHLY EARNED NET INCOME:
enter after tax "monthly" income or N/A if you do not work
AMOUNT OF OTHER MONTHLY INCOME:
this includes SSI, SSDI, VA BENEFITS...
MEANS OF PAYMENT: (CHECK ALL THAT APPLY)
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SSI
SSDI
SOCIAL SECURITY
RETIREMENT SAVINGS
EMPLOYEE SALARY
FAMILY MEMBER
VA
Other
LIKELY METHOD OF PAYMENT: CASH IS NOT ACCEPTED
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ZELLE
PAYPAL
WEBSITE PAYMENT
MY BANKS BILL PAY SITE
Other
PREFERRED MEMBERSHIP TERM:
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1-3 MONTHS
4-6 MONTHS
7-9 MONTHS
10-12 MONTHS
1+ YEARS
HOW SOON ARE YOU LOOKING TO MOVE?
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Month
-
Day
Year
Date
EMERGENCY CONTACT PERSON:
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enter "hospital" if you do not have an emergency contact person to list
RELATIONSHIP TO EMERGENCY CONTACT PERSON:
*
enter "hospital" if you entered "hospital" above
EMERGENCY CONTACT PERSON PHONE NUMBER:
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-
Area Code
Phone Number
DO YOU HAVE A VEHICLE TO PARK ON THE PROPERTY?
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YES
NO
HAVE YOU EVER BEEN CONVICTED OF A FELONY?
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YES
NO
ARE YOU A SEX OFFENDER?
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YES
NO
IF YOU ANSWERED YES TO THE FELONY OR SEX OFFENDER QUESTION, PLEASE PROVIDE YEAR OF INCIDENT AND DETAILS:
enter N/A if this doesn't apply
PROBATION OR PAROLE STATUS:
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enter N/A if this doesn't apply
PROBATION OR PAROLE OFFICER NAME AND PHONE NUMBER:
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enter N/A if this doesn't apply
DO YOU SMOKE?
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YES
NO
DO YOU DRINK ALCOHOL?
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YES
NO
PLEASE LIST FOOD ALLERGIES
FAVORITE COLOR(S):
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FAVORITE FOOD(S):
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FAVORITE RESTAURANT:
*
FAVORITE TV SHOW:
FAVORITE MOVIE:
FAVORITE ACTOR OR ACTRESS:
FAVORITE BOOK:
FAVORITE MUSIC GENRE:
FAVORITE SINGER, BAND OR GROUP:
FAVORITE PAST TIME/HOBBY:
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TYPICAL SLEEPING HOURS:
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ex: 10pm-6am
PREFERRED AREA OF GEORGIA TO LIVE:
INSTAGRAM NAME:
FACEBOOK NAME:
ANY ADDITIONAL INFORMATION YOU WOULD LIKE TO INCLUDE?
BY CHECKING AGREE, I UNDERSTAND THAT I AM APPLYING TO BECOME A MEMBER IN AN INDEPENDENT CO-LIVING HOUSING PROGRAM. COMPLETING THIS FORM DOES NOT GUARANTEE PLACEMENT. IF APPROVED, UPON SIGNING THE MEMBERSHIP AGREEMENT, I AGREE TO PAY THE ONE TIME $100 NON-REFUNDABLE CLEANING FEE AND THE MONTHLY FEE WILL COVER MY BED AND ALL UTILITIES. I AGREE TO FOLLOW ALL HOUSE RULES AND EXPECTATIONS. I ACKNOWLEDGE THAT VIOLATING RULES MAY RESULT IN IMMEDIATE DISMISSAL FROM THE PROGRAM WHICH INCLUDES IMMEDIATE DISMISSAL FROM THE HOME.
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AGREE
BY SIGNING BELOW AND SUBMITTING THIS FORM, YOU AGREE THAT YOU HAVE PROVIDED ACCURATE INFORMATION.
SIGNATURE:
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Should be Empty: