Independent Living Program Registration
Please complete this registration form using the information from the intake PDF. Keep responses close to the original wording where possible. Fields should default to optional unless the source document clearly requires them.
Applicant Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Address
*
Referral Source
Income and Benefits
Do you have a steady source of income?
*
Yes
No
Main Source of Income
SSI
SSDI
Employment
VA Benefits
Other
Estimated Monthly Income
Do you receive SNAP / EBT benefits?
Yes
No
Daily Living and Health
Able to live independently without daily assistance?
*
Yes
No
Currently receive help with daily activities?
*
Yes
No
Currently taking prescribed medications?
*
Yes
No
Difficulty accessing medications?
*
Yes
No
If yes, please explain
Physical disabilities or mobility concerns?
*
Yes
No
Explanation
Housing Preferences
Preferred Room Type
*
Shared
Private
Private w/Bathroom
No Preference
Desired Move-In Date
*
-
Month
-
Day
Year
Date
Eligibility and House Rules
Ever been evicted from a residence?
*
Yes
No
Ever been convicted of a felony?
*
Yes
No
Registered sex offender?
*
Yes
No
Willing to follow house rules and cleanliness standards?
*
Yes
No
Do you smoke?
*
Yes
No
Do you have any pets?
*
Yes
No
Additional Information and Submission
Why are you seeking housing at this time?
*
Anything else you'd like us to know?
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Staff Name
Application Status
*
Please Select
Draft
Submitted
Under Review
Approved
Waitlisted
Denied
Other
Notes
Save
Submit
Submit
Should be Empty: