Surpassing Hurdles Reentry Housing Application Form
Complete this form to apply for the Surpassing Hurdles Reentry Housing Program. Please provide accurate information and review all program requirements before submitting.
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I confirm that I am 30 years of age or older.
*
Yes
No
Email Address
*
example@example.com
Emergency Contact
Emergency Contact Full Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to You
*
Current Living Situation
What is your current living situation?
*
Shelter
Transitional Housing
With Family/Friends
Street/Homeless
Other
How long have you been in your current situation?
Income Information
Do you currently receive any of the following income sources?
*
SSI
SSDI
Employment Income
None
Other
Please specify your total monthly income (USD)
*
Employment Status
What is your current employment status?
*
Employed Full-Time
Employed Part-Time
Unemployed
Looking for Work
Unable to Work
Interest in Home Care Services (Preferred but not required)
Yes, I am interested
No, not at this time
Background Information
Do you have any criminal history?
*
Yes
No
Are you currently on parole or probation?
*
Yes
No
Do you have any medical conditions, disabilities, or support needs we should be aware of?
Payment Terms
Program fees are due on the 1st of each month. Payments are considered late after the 5th. Failure to pay by the 5th may result in termination of the program agreement and required move-out.
Furnishing & Personal Belongings Policy
The home is fully furnished. Residents may only bring minimal personal belongings such as clothing and hygiene items. Furniture and excessive items are not permitted.
I understand and agree to the Furnishing & Personal Belongings Policy.
*
Program Agreement and Rules
Program Rules:
No guests policy
12am curfew unless working
Fees:
6-month program agreement with monthly program fees ($750 shared room, $900 private room) and security deposit required.
I acknowledge and agree to the program rules, 6-month agreement, monthly fees, and security deposit requirement.
*
I Agree
I Do Not Agree
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Move-In Acknowledgment
The home is fully furnished. No guests are allowed, curfew is 12 AM unless working, and payments are due on the 1st and considered late after the 5th.
I understand and agree to all program rules and expectations before submitting this application.
*
Submit Application
Submit Application
Health and Support Needs
Should be Empty: