LONG-TERM MEMBERSHIP APPLICATION
Thank you for your interest in The Queendom Reserve. This application helps us understand your current situation, housing needs, preferences, and support needs. Submission of an application does not guarantee acceptance or placement. Applications must complete the review and screening process and meet current program eligibility and availability.
1. APPLICANT INFORMATION
Full Legal Name: *
*
First Name
Last Name
Preferred Name:
First Name
Last Name
Date of Birth: *
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Phone Number: *
*
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
Email Address: *
*
example@example.com
Current Address (if applicable):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender Identity: *
*
Female
Male
Non-Binary
Prefer not to say
Other text input
How did you hear about The Queendom Reserve? *
*
2. EMERGENCY CONTACT INFORMATION
Name: *
*
First Name
Last Name
Relationship: *
*
Phone Number: *
*
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3. REFERRAL INFORMATION (IF APPLICABLE)
Referred By (Agency/Individual):
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Relationship/Title:
4. MEMBERSHIP DETAILS
Requested Membership Type: *
*
Shared Room
Private Room
Preferred Move-In Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected Length of Stay:
5. CURRENT HOUSING SITUATION
Current Living Situation: *
*
Homeless / Unsheltered
Shelter
With Family or Friends
Hospital / Medical Facility
Transitional Program
Other
Reason for Seeking Services (optional):
6. INCOME, EMPLOYMENT & BENEFITS
Employment Status: *
*
Employed (Full-Time)
Employed (Part-Time)
Unemployed
Not Able to Work
Monthly Income Source(s):
Wages
SSI
SSDI
TANF
Unemployment
Other
Approximate Monthly Income: $
Do you have a representative payee?
Yes
No
If yes, name/agency:
7. TRANSPORTATION NEEDS
Do you require transportation support?
Yes
No
If yes, what type of support is needed?
Medical Appointments
Shopping/Errands
Employment
Community Resources
Other
8. ADDITIONAL INFORMATION
Are there any medical conditions, disabilities, or accommodations we should be aware of?
Any additional information you would like to share?
9. ACKNOWLEDGMENT & SIGNATURE
I certify that the information provided on this application is true and complete to the best of my knowledge. I understand that false or incomplete information may affect my eligibility for membership. I also understand that submission of this application does not guarantee acceptance or placement. I agree to provide any additional information or documentation as requested during the review and screening process.
Applicant Signature: *
*
Date: *
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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