Pre-Screening
Thank you for your interest in 711 Living & Leisure Ltd Co, Independent Living Division. Please complete this pre-screening form below with accurate and honest information. Submission of this form does not guarantee placement. Contact will be made once reviewed.
Applicant Information
First Name
*
Last Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Eligibility and Housing Fit
Are you a
*
Please Select
Veteran
Single Parent
Aged Out Foster Youth (18-24)
Do you understand this is shared room-based housing, not an apartment?
*
Please Select
Yes
No
Do you have verifiable income?
*
Please Select
Yes
No
Are you able to live completely independently?
*
Please Select
Yes
No
Are you able and willing to follow house rules and participate in check-ins?
*
Please Select
Yes
No
Do you have any substance use issues?
*
Please Select
Yes
No
If yes, are you actively in treatment or in recovery?
*
Please Select
Yes
No
N/A
Room Need and Household Details
Which type of room do you need?
*
Please Select
Veteran/Aged Foster Youth - Shared ($850 Month)
Single Parent (2 Kids Max) – Private ($1000)
Child 1 - gender and age
Child 2 - gender and age
How soon do you need to move in?
*
Please Select
ASAP
Within 30 Days
Within 60 Days
How long do you need to stay?
*
Please Select
Up to 3 months
3 - 6 months
6 months+
Program Agreement and Submission
Do you agree to follow the program rules?
*
Yes
No
Do you understand cameras are in communal areas and exterior spaces?
*
Yes
No
Additional information or exceptional circumstances
Signature of Applicant
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: