Light House Ministries Entry Application

Light House Ministries Entry Application
P.O. Box 54, Keller VA 23401
(757) 787-2535
(All questions MUST BE answered)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Name
Referral Phone:
Format: (000) 000-0000.
Name

First NameMiddle Name
Last Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Race:
Gender:
Phone:
Format: (000) 000-0000.
Current Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address, if different:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a job?
Where?
Do you have Transportation?
# of people in Household (Including applicant) who need housing?
Must complete information on each one (separate form) and other adults will also need to complete own form.

Where have you slept in the past 30 days (check all that apply):

Rows	Describe/Name of Location
Non-housing (car, street, park, etc)
Emergency Shelter (including Domestic Violence)
Transitional Housing
Psychiatric Facility
Substance Abuse Treatment Facility
Rental /Own Home
With Friends/Families
Prison/Jail
Other

Rows	Monthly Income & Amount	Reason for Leaving Last Housing Situation:	Family Type
Child Support:
TANF:
Employment FT:
Employment PT:
Pension:
Veterans Ben.:
SSA:
SSI:
Unemployment:
SNAP:
Other:
Total:
Medicare
Other Insurance

Applicant Name:

First NameLast Name

Please list any past or present charges you have against you. We will do a background prior to contacting you. Having charges does not necessarily disqualify but lying will so just be honest.

Rows	Charge	Date	Locality	Probation/parole(Y/N)
1
2
3
4

Are there any domestic violence concerns?
Are you presently using alcohol or drugs?
Have you had problems in the past with alcohol or drugs? If so, explain & when did you last use?

Rows	Medical/Psychiatric Diagnoses	Medications
1
2
3
4

**USE SEPARATE FORM FOR ADDITONAL FAMILY MEMBERS***

MUST List 3 References: Preferably Pastor, Case Worker, Neighbor, Friend, Family Member, Landlord

Rows	Name	Phone #	Relationship	Agency, if applicable
1
2
3

Application Affirmation & Authorization to Verify Information
APPLICATION STATEMENT: I certify that the above information is an accurate & complete disclosure of the requested information. I hereby acknowledge that the information relating to determination of my eligibility requires verification and/or documentation, and by my signature, I authorize the release of such information as may be required for the determination of my eligibility.
Signature of Applicant
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I also understand that to stay at Light House Ministries, I will have to follow the rules. Some of these rules include, but are not limited to: leaving premises daily, random drug testing; chores done every day, room must remain clean & bed made; must attend at least one church service on Sunday; and abide by 9p.m. curfew. More information will be provided. I agree that if I, or anyone in my "household" fails to comply, I/we will be unable to stay.
Signature of Applicant
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Revised 3/2025

Applicant Name

First NameLast Name

Other Household Information (MINORS ONLY): ADULTS MUST COMPLETE OWN FORM

Rows	Name (Not Applicant)	Relationship to Applicant	Date of Birth xx/xx/xxxx	Age	Gender M/F
1
2
3
4
5
6

Rows	Name	Major Medical/Psychiatric Diagnoses	Medications
1
2
3
4

Monthly Income & Amount for Household (not Applicant)
Name:
Child Support:
TANF:
SSA:
SSI:
Unemployment:
SNAP:
Other:
Total:
Other Insurance
Name:
Child Support:
TANF:
SSA:
SSI:
Unemployment:
SNAP:
Other:
Total:
Other Insurance
Name:
Child Support:
TANF:
SSA:
SSI:
Unemployment:
SNAP:
Other:
Total:
Other Insurance
Application Affirmation & Authorization to Verify Information
APPLICATION STATEMENT: I certify that the above information is an accurate & complete disclosure of the requested information. I hereby acknowledge that the information relating to determination of my eligibility requires verification and/or documentation, and by my signature, I authorize the release of such information as may be required for the determination of my eligibility.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Light House Ministries Entry Application

Application Affirmation & Authorization to Verify Information

Monthly Income & Amount for Household (not Applicant)

Application Affirmation & Authorization to Verify Information