Resident Housing Application
Complete your initial shared-housing application and confirm your contact details for follow-up.
Full Name
*
First Name
Last Name
Preferred Name (if different)
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current City and State
*
Desired Move-In Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please describe your housing needs or preferences (optional)
Employment/Income/Funding Source
*
Employment income
SSI/SSDI
Veterans benefits
Pension/retirement
Housing assistance
Other benefits/funding
Other
Approximate monthly income or funding amount (USD)
*
Can you reliably meet the monthly housing cost?
*
Yes
No
Unsure
Ability to live independently without daily assistance from onsite staff
*
Fully independent
Occasionally receives outside assistance
Requires regular assistance
Are you comfortable with shared housing?
*
Yes
No
Unsure
Current housing situation (optional)
Reason for seeking housing (optional)
Any relevant household/shared-living considerations (optional)
How did you hear about Root & Rise Living?
Please Select
Referral from friend/family
Social media
Online search
Community organization
Other
Emergency Contact Full Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
*
Submit Application
Should be Empty: