Main Haven Living | Resident Application & Intake
Independent Living for Adults 55+ 2241 Sullivan Rd., Augusta, GA 30901 (706) 284-8881 • www.MainHavenLiving.com • support@mainhavenliving.com
Main Haven Living | Independent Living for Adults 55+ | 2241 Sullivan Rd., Augusta, GA 30901 | Phone: (706) 284-8881 | Website: www.MainHavenLiving.com | Email: support@mainhavenliving.com
Date of Intake:
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Mes
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Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
PERSONAL INFORMATION
Full Name:
*
First Name
Last Name
Date of Birth:
*
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Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
Gender:
Current Address:
Dirección de la calle
Dirección de la calle Línea 2
Ciudad
Estado / Provincia
Código Postal / Zip
Phone Number:
*
Format: (000) 000-0000.
Email (if applicable)*:
ejemplo@ejemplo.com
* If you do not have an email, one will be created for you. The username and password will be provided to you at or before move-in. This is the official communication channel.
EMERGENCY CONTACTS
Primary Contact Name:
First Name
Last Name
Primary Contact Relationship:
Primary Contact Phone:
Format: (000) 000-0000.
Secondary Contact Name:
First Name
Last Name
Secondary Contact Relationship:
Secondary Contact Phone:
Format: (000) 000-0000.
Emergency Contact Authorization
— I authorize the program to contact the people listed above in case of emergency and to release necessary information for safety purposes.
Resident Initials:
HOUSING NEEDS
Current Living Situation (check one):
Homeless
Couch Surfing
Shelter
Transitional Program
Other
Monthly Income: $
Are you currently employed?
Yes
No
Monthly contribution discussed ($)
Can you pay the monthly contribution discussed with Main Haven?
Yes
No
Not yet discussed
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Room Preference
Private
Shared (Semi-Private)
No Preference
BENEFITS
Current Benefits Received (check all that apply):
SSI
SNAP
SSDI
VA Benefits
Other
BACKGROUND
Do you have a criminal background?
Yes
No
Do you have a history of substance use?
Yes
No
Do you have any medical conditions?
Yes
No
Do you smoke or vape?
Yes
No
If yes to any of the above, please explain:
Please initial each statement:
I understand participation in the program may require a background check for the safety of all residents. Initials:
I consent to a criminal background check. Initials:
I have provided accurate information regarding any prior convictions. Initials:
ROOMMATE PREFERENCE
Preferred Lifestyle:
Quiet
Active
No Preference
Other Preferences:
Are you comfortable sharing a room with others?
Yes
No
REFERENCE (optional but helpful)
Reference Name:
First Name
Last Name
Reference Relationship:
Reference Phone:
Format: (000) 000-0000.
Reference Email:
ejemplo@ejemplo.com
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IDENTIFICATION VERIFICATION
Please attach a copy of your government-issued ID.
Upload a copy of your government-issued ID:
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Identification Type (check all provided):
Driver's License
Passport
State ID
Social Security Card
Other
CERTIFICATION
I certify that all the information provided on this form is true and complete to the best of my knowledge.
Signature:
*
Certification Date:
*
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
Main Haven Living
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