Jones Haven for Women & Children – Family Program Overview & Community Living Addendum

Jones Haven for Women & Children – Family Program Overview & Community Living Addendum

Complete this pre-move-in addendum to confirm your household’s placement details and shared community expectations.
Participant and Placement Information
Parent/Guardian Full Legal Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Property Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Assigned Bedroom/Room
Anticipated Move-In Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approved Household Member Names
Number of Adults
Number of Children
Total Household Size
Placement Type
Monthly Program Fee
One-Time Community Fee
Payment Due Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Third-Party Payer or Sponsor (if applicable)
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Only approved household members may reside in the home. Any changes to household composition require advance written approval.
Family Program Structure
Assigned Family Bedroom and Placement
Shared and Designated Common Spaces Acknowledgment
Placement and Assignment Conditions
Acknowledgment of Room, Bed, and Property Restrictions
Transitional and Housing-Stability Focus
Describe your current plan for long-term housing stability
List the steps you will take to maintain income or approved funding and manage expenses
Acknowledgment of transitional housing-stability terms
Parent/Guardian and Child Responsibilities
I acknowledge the Parent/Guardian & Child Safety Responsibility Agreement and my responsibilities for supervision, childcare, transportation, education, meals, hygiene, medication, appointments, daily needs, and ensuring my children respect others’ safety, privacy, rest, property, and peaceful use.
Which responsibilities do you confirm you understand and accept?
If needed, note any child-specific support needs or exceptions related to these responsibilities.
Shared Common Areas
Acknowledgment of Shared Common Area Expectations
Shared Area Responsibilities Checklist
Laundry Schedule Preference
Bedrooms, Furnishings, and Personal Property
Acknowledgment of bedroom, furnishings, and personal property rules

I understand that only assigned bedrooms, beds, storage, and furnishings may be used; children may not enter another household’s bedroom without permission and supervision; furnishings remain assigned unless approved; and I will promptly report damage, maintenance concerns, pests, leaks, broken locks, or other hazards. I also understand that responsibility for belongings is subject to applicable law.
Damage, maintenance, or hazard report details
Personal property and belongings notes
Visitors, Overnight Guests, and Access
Visitors, overnight guests, and access are regulated by house policy and applicable orders. Approved case managers, service providers, inspectors, maintenance workers, and other professionals may enter only by appointment or as otherwise legally permitted.
I understand and acknowledge the visitor and access rules, including that no overnight guests or unapproved occupants are allowed, and that relatives, another parent, emergency contacts, babysitters, and drivers do not automatically have entry permission.
I understand that custody orders, visitation orders, and protection orders must be followed at all times.
Community Conduct and Privacy
Acknowledgment of community conduct and privacy rules
I understand that the following are prohibited: violence, threats, harassment, bullying, discrimination, intimidation, unsafe behavior, sharing keys or access codes, and sharing private information
I understand that photographing, recording, livestreaming, posting, or identifying another resident or child is not allowed without permission, except for immediate safety documentation for authorities or management
Childcare, School, Transportation, and Activities
The program does not provide childcare, school or daycare enrollment assistance, school or activity transportation, or custody services. The parent or guardian is responsible for maintaining primary and backup arrangements for childcare, school, and activities.
Please acknowledge that you understand the parent or guardian is solely responsible for childcare, school, transportation, and activity arrangements, and that no resident, staff member, owner, or contractor is presumed to supervise or transport any child.
Which arrangements do you confirm you have in place for your child(ren)?

Other
Health, Medication, and Emergencies
The program does not provide medical care, behavioral-health treatment, medication administration, or ongoing monitoring. Parents/guardians are responsible for securing all medication and hazardous items, obtaining needed care, calling 911 in emergencies, and keeping emergency contact information current.
Acknowledgment
Emergency information or special health instructions
Security and Cameras
I acknowledge the camera and security rules for common and exterior areas

Other
I understand where cameras are allowed and not allowed

Other
Security and camera acknowledgment checklist
Payments and Financial Responsibility
Acknowledgment of payment responsibility and funding status
Acknowledgment of written notice for fee or funding changes
Additional payment or funding details
Communication, Concerns, and Reasonable Accommodation
Which concerns are you reporting today?

None
Describe the concern or issue
Do you have a current accommodation request?
If yes, describe the accommodation requested and any relevant details
Acknowledgment
Relationship to Existing Documents
This addendum supplements the Universal Program Overview & Participation Handbook, Universal Code of Conduct, Universal Program Participation Agreement, Universal Security Monitoring and Camera Acknowledgment, Universal Income Verification, Universal Resident Onboarding Information, Parent/Guardian & Child Safety Responsibility Agreement, and Child & Household Information Form.
All applicable onboarding documents must be completed before move-in. Property-specific written housekeeping instructions may supplement general procedures, subject to applicable law. This addendum does not waive rights or obligations under applicable law.
Acknowledgment
Final Certification and Signature
Overall Agreement
Parent/Guardian Printed Name

First NameMiddle NameLast Name
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Program Representative Name

First NameMiddle NameLast Name
Comments
Should be Empty:

Jones Haven for Women & Children – Family Program Overview & Community Living Addendum

Participant and Placement Information

Family Program Structure

Transitional and Housing-Stability Focus

Parent/Guardian and Child Responsibilities

Shared Common Areas

Bedrooms, Furnishings, and Personal Property

Visitors, Overnight Guests, and Access

Community Conduct and Privacy

Childcare, School, Transportation, and Activities

Health, Medication, and Emergencies

Security and Cameras

Payments and Financial Responsibility

Communication, Concerns, and Reasonable Accommodation

Relationship to Existing Documents

Final Certification and Signature