Waiting List for ALL

The Cynoya - Independent Living Waiting List Form

Please fill out this form completely to help determine eligibility
How did you hear about us?
Participant Name*

First NameLast Name
Most Recent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMaleOther
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Current Living Situation*

HomelessIncarceratedMotel/HotelTransitional ProgramCar/StreetFamily/FriendsOther
- Employment Status*
  
  EmployedDisabilityUnemploymentSeeking EmploymentSpousal/Child SupportOther
- Source of Income (check all that apply)*
  
  Social SecurityEmploymentDisabilityNoneOther
- Monthly Income Amount*
- Preferred Housing Location*
  
  Baltimore CityBaltimore CountyWashington, DCOther
- If Other, please select a State for Referral:
- Room Type Request*
  
  Shared RoomPrivate Room
- Move-in Date Requested*
- Have you ever lived in shared housing before?*
  
  YesNo
- Do you have any of the following? (check all that apply)
  
  Probation OfficerCase WorkerSocial WorkerSupport WorkerOther
- If Yes, list name + contact
- Are there any background concerns we should be aware of? (for safety purposes only)*
  
  IncarceratedMental HealthDomestic Violence SurvivorMedical IssuesOther
- Emergency Contact Name*
  
  First NameLast Name
- Email*
  example@example.com
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Relationship*
- Copy of Identification Front
  
  Cancelof
- Copy of Identification Back
  
  Cancelof
- I acknowledge that The Cynoya Independent Living Housing offers shared housing with established house rules, expectations, and program guidelines designed to ensure a safe, respectful, and clean living environment for all residents. I agree to comply with all rules and to complete the intake process truthfully and in good faith.
- Signature
Should be Empty:

The Cynoya - Independent Living Waiting List Form