Surpassing Hurdles Reentry Housing Waitlist Form
Please fill out this form to join the waitlist and provide your details for consideration.
Full Name
*
First Name
Last Name
Date of Birth (must be 30 or older to qualify)
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Current Living Situation
*
Please Select
Homeless (shelter)
Homeless (unsheltered)
Staying with friends/family
Transitional housing
Currently incarcerated
Other
Desired Room Type
*
Shared
Private
Monthly Income Source
*
SSI/SSDI
Employment
Other
Employment Status
*
Please Select
Employed full-time
Employed part-time
Unemployed
Unable to work
Other
I agree to the following program rules: No guests permitted; 12am curfew unless working; payments due on the 1st and late after the 5th; fully furnished, minimal belongings only.
*
I agree to the program rules above
Preferred Move-In Timeline
*
Please Select
As soon as possible
Within 30 days
1-3 months
More than 3 months
I understand this is a waitlist application and does not guarantee housing placement.
*
I acknowledge this is a waitlist only
Join Waitlist
Can you pay the first month's rent and security deposit?
*
Yes
No
Need assistance
Should be Empty: