Family Application. Hillcrest Transitional Housing FAMILY PROGRAM APPLICATION Step 1 of 11 9% GENERAL INFORMATION Please select your first choice of housing location.* Independence Lee's Summit St. Joseph Kansas City, KS Overland Park, KS (limited availability) If you want to be considered for mutiple housing sites, enter an Alternate Location(s) from the choices below: Lee’s SummitIndependenceSt. JosephKansas City KSOverland Park KS Applicant Name* Please enter your first and last name: First Last Applicant Phone* Applicant Email Is there a co-applicant (spouse/significant other)? Yes No Co-applicant* Please enter your co-applicant first and last name: First Last Co-Applicant Phone CURRENT LIVING ARRANGEMENT Where are you living right now? (select one): House / Apt.FriendsRelativesShelterHotelStreetCarOther Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country How long have you lived at this address? Have you been asked to leave your current living situation? Yes No If Yes, How long can you stay there? 24 hours1 Week2 Weeks1 Month Have you ever lived at Hillcrest before? Yes No Who referred you to Hillcrest? HOUSEHOLD INFORMATION List all who would be living in the apartment (including yourself):* (click the plus sign to add another person) Name Relationship Date of Birth SS# (last four) Grade/School Race Hispanic? Yes/No Have you or a member of your household (those living with you currently) been diagnosed with a disabling condition? Disabling conditions include physical, emotional & developmental disabilities, as well as chronic substance & alcohol abuse. Household Member Disabling Condition Other Information You Would Like to Share Anyone pregnant? Yes No When is the due date for the pregnancy? HOUSEHOLD EXPENSES List all Bills and Debts:* Please add an item for each of the following that apply: Past Rent, Cable, Electric, Gas, Telephone, Water, Student Loans, Medical, Clubs, Child Support, Repossessions, Bad Checks, Pawn Shop, Payday Loans, Tickets/Fines, Bankruptcy, Credit Cards, Storage, Childcare, Auto Payment, Auto Insurance, Title Loans, Cell/Pager, Other (click the plus sign to add another bill/debt) Item Amount Due Monthly Payment Past Due? (Yes or No) HOUSEHOLD INCOME List CASH & NON-CASH Income currently received from a Job, Food Stamps, TANF, DFS (childcare/transportation assistance), SSI/SSDI, Medicare/Medicaid, SCHIP/Health Wave/HealthNet, etc. List EACH SOURCE separately, by Source & Monthly Amount Received. If child support is owed to you, please list monthly/total amount owed. (click the plus sign to add another income source) Source Monthly Amount SOCIAL SERVICES Please explain briefly the reasons for your current situation (Why you are Homeless or Losing your Housing). Please state WHERE you are staying, WHY you have to leave, and WHEN you must leave:* Do you currently have a Family Services/DSS case worker? Yes No Case Worker Name: Case Worker Phone Number: Name of Social Services Office: MEDICAL AND COUNSELING SERVICES Do you or any family members receive any medical or counseling services? Yes No If Yes, please list the family members (click the plus sign to add another medication) Family Member Problem Medication TRANSPORTATION INFORMATION Drivers License Number Driver's License State or State of ID Please enter your driver's license state or the state of your state issued id? ID Expiration Please enter the expiration date of you driver's license or state issued ID. Do you have your own car? Yes No Year of Car* Make and Model of Car* Do you have car insurance?* Yes No Car Tag Number:* Are your Tags Current?* Yes No Is your car inpection current?* Yes No Please add the state your car's tag are registered.* Please list References/Emergency Contacts: (click the plus sign to add another contact) Name Address Phone Relationship PERSONAL HISTORY Age Please enter a value between 1 and 100. SS# (last four digits)* Date of Birth Location of Birth Marital Status Married Single Divorced Separated Widowed Do you have previous marriages? Yes No Please select highest education level you attained Select LevelGrades 1- 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Some CollegeCollege Degree Please select the average grade you earned during your education. Select GradeABCDF Please enter the name(s) of the school(s) and year graduated. (click the plus sign to add another school) Level (High School, GED, College, etc.) Name of School Year Graduated If you are a military Veteran, which branch did you serve in, and what years? Military Branch Years Served Please list your job history (Last 5 Years):* (click the plus sign to add another job) Year(s) worked at Job Company Name Pay Rate Duties Reason for Leaving/Current Job? Please list your family members (click the plus sign to add another family member) Parents Names Address (city, state) Phone Please list your Brothers and Sisters (click the plus sign to add another sibling) Brother/Sister Name Address (city, state) Phone Do you smoke? Yes No How much do you smoke per day? Do you use drugs or alcohol? Yes No Have you ever been in drug or alcohol rehabilitation? Yes No If Yes, When? What is the name of abused substance? What rehabilitation facility did you attend? Are you an AA participant? Yes No Are you an NA participant? Yes No Have you ever been arrested? (DWI, Bad Checks, Assault, ect.) Yes No If Yes, What for? Did you receive a fine/sentence? Yes No Have you been a battered person? Yes No If Yes, When were you battered? Have you served any time in jail? Yes No If Yes, How long were you in jail? Do you have any pending tickets? (speeding, parking, ect.) Yes No If Yes, What were the pending tickets for? When is your court date? Are you on parole or probation at present? Yes No If Yes, How long? Parole/Probation Officer: Parole/Probaton Officer Phone Number Is there a warrant(s) out for your arrest at present? Yes No If Yes, Reason for Warrant(s) CO-APPLICANT PERSONAL HISTORY Age: Please enter a value between 1 and 100. SS# (Last for digits) Date of Birth Location of Birth Marital Status Married Single Divorced Separated Widowed Has co-applicant been previously married? Yes No Please select the highest level of education co-applicant attained Select LevelGrades 1- 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Some CollegeCollege Degree Please select the average grade co-applicant earned during their education Select GradeABCDF Please enter the name(s) of the school(s) and year graduated. (click the plus sign to add another school) Level (High School, GED, College, etc.) Name of School Year Graduated If you are a military Veteran, which branch did you serve in, and what years? Military Branch Years Served Please list co-applicant job history (Last 5 years) (click the plus sign to add another job) Year Company Name Pay Rate Duties Reason for Leaving Please list co-applicant family members (click the plus sign to add another family member) Parents Names Address (city, state) Phone Please list co-applicant Brothers and Sisters (click the plus sign to add another sibling) Brother/Sister Name Address (city, state) Phone Does the co-applicant smoke? Yes No How much does the co-applicant smoke per day Does the co-applicant use drugs or alcohol? Yes No Has the co-applicant ever been to drug or alcohol rehabilitation? Yes No If Yes, When?: Please enter the name of the abused substance: Please enter the name of the facility the Co-Applicant attended during rehabilitation. Is the co-applicant an AA participant? Yes No Is the co-applicant a NA participant? Yes No Has the co-applicant ever been arrested? (DWI, bad checks, assault, ect.)? Yes No If Yes, What for? Did the co-applicant receive a fine/sentence? Yes No Has the co-applicant been a battered person? Yes No If Yes, When? Has the co-applicant served any jail time? yes no If Yes, How long? Does the co-applicant have any pending tickets? (speeding, parking, ect.) Yes No If Yes, What for? When is the co-applicant's court date? Is the co-applicant on parole or probation at present? Yes No If Yes, who is the co-applicant's parole/probation officer What is the co-applicant's parole/probaton officer's phone number Is there a warrant(s) out for the co-applicant's arrest at present? Yes No Please describe the reason for the co-applicant warrant(s)? Programs Rules The following rules of conduct shall be in effect while Clients participate in the Hillcrest Transitional Housing program. Violation of any rule will, at the sole discretion of the Board or Staff, be cause for immediate dismissal from the program, causing forfeiture of shelter space & supportive services. No illegal activity of any kind will be permitted Use or possession of alcohol, firearms or illegal drugs is prohibited. Curfew is 11:00 pm. This can only be waived for work schedules. Your Guests must be out of the shelter buildings by 10:00 pm. Quiet hours are: 10:00 pm through 7:00 am. No overnight guests are allowed unless permission is obtained through a staff member. Children under the age of 13 must be attended by an approved adult at all times. Children must be enrolled in the school district nearest Hillcrest or in the district your family originates from. They must attend school everyday required.. No fighting of any kind will be tolerated. No pets of any kind will be allowed. Smoking is NOT permitted inside the shelter units, buildings, or offices. Clients must keep shelter units & common areas clean and neat. All adults in the Hillcrest program are expected to work at least 40 hours per week. All adults must attend scheduled meetings & appointments. A $100 program deposit will be taken at time of shelter entry, or at time of first paycheck. I acknowledge that Hillcrest staff may enter my shelter unit to do maintenance or cleaning checks when I am not present without notification beyond immediate announcement. I acknowledge the Hillcrest staff will also perform scheduled checks of my shelter unit. I acknowledge that Hillcrest staff may require me to submit to random drug testing while I am participating in the transitional housing program, and that my refusal to do so could result in being asked to immediately vacate the program. I have read and understand that if I violate any one of these rules I may be dismissed from the Hillcrest program. I agree to hold Hillcrest Transitional Housing and/or any other parties associated with this program in any way whatsoever, singly, or collectively, from any blame or liability for injury, misadventure, harm, loss, inconvenience, or damage suffered or sustained as a result of participation in this program or in activities associated therewith. I give permission for information to be released about me and my children, by or to any doctor, social worker, counselor, employer, landlord, shelter, agency, including Mid America Assistance Coalition & Rosie HMIS databases, or any other person deemed necessary by Hillcrest Transitional Housing. I agree that my acceptance into the Hillcrest Transitional Housing Program is not a rental agreement, and that this is not a landlord/tenant agreement, but an application for temporary homeless shelter & supportive services provided by the Hillcrest program. By submitting this application, I agree that the preceding information is true and accurate to the best of my knowledge, and I understand and agree to the Rules as put forth above.