Hillcrest Transitional Housing
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Program Application


GENERAL INFORMATION:
Select a Location:
Liberty   Avondale    Independence   Lees Summit    KC North   Platte City
Kansas City, KS
Select an Alternate Location(s):
Applicant First Name: Applicant Last Name:
Co-Applicant First Name: Co-Applicant Last Name:
Phone Number:

Where are you living right now? (select one):
Address: Phone:
How long have you been staying there?

Have you been asked to leave your current living situation? Yes   No
How long can you stay there?

Have you ever lived at Hillcrest before? Yes   No

Referred to Hillcrest by:



List all who would be living in the apartment (including yourself):
Name Relationship Date of Birth Soc. Sec. # Grade/School Race Hispanic?
Yes/No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Anyone pregnant?  YesNo     Due Date:  


Bills and Debts: (complete the attached list and add any items not listed)
Item Amt Due Mo Payment Past Due?   Item Amt Due Mo Payment Past Due?
Past Rent Yes
No		   Pawn Shop Yes
No
Cable Yes
No		   Payday Loans Yes
No
Electric Yes
No		   Tickets/Fines Yes
No
Gas Yes
No		   Bankruptcy Yes
No
Telephone Yes
No		   Credit Cards Yes
No
Water Yes
No		   Storage Yes
No
Student Loan Yes
No		   Childcare Yes
No
Medical Yes
No		   Auto Payment Yes
No
Clubs Yes
No		   Auto Insurance Yes
No
Child Support Yes
No		   Title Loans Yes
No
Repossessions Yes
No		   Cell/Pager Yes
No
Bad Checks Yes
No		   Other Yes
No
Other Yes
No		   Other Yes
No
Other Yes
No		   Other Yes
No


Income currently received from Job, Food Stamps, TANF, DFS, SSI, etc.:
If child support is owed to you, please list monthly/total amount owed.
Source Monthly Amount

Current Case Worker Name?     Phone #:  

Name of Social Services Office:  


Please explain briefly the reasons for your current situation:


Do you or any family members receive any medical or counseling services?
Name Problem Medication


Drivers License Number:     State:    Expiration: 
Do you have a car? YesNo
   Year:     Model:     Insurance? YesNo
   Tag Number:     Current? YesNo    State:     Current Inspection? YesNo


References/Emergency Contact:
Name Address Phone Relationship

APPLICANT PERSONAL HISTORY:
Age:    Social Security Number:    Date of Birth:
Location of Birth:
Married   Single   Divorced   Separated   Widowed     Previous marriages? Yes No


Education
Level: (select one)     School Grade Average (select one)

Name of School Year Graduated
High School/GED
College


Job History Information (Last 5 Years):
Year Company Name Pay Rate Duties Reason for Leaving


Family
Parents Names Address (city, state) Phone


Brothers/Sisters Names Address (city, state) Phone


Do you smoke? Yes No    How much per day?

Do you use drugs or alcohol? Yes No

Ever been in drug or alcohol rehabilitation? Yes No
    If yes, when:    Name of abused substance:
    Facility:    AA Participant? YesNo    NA Participant? YesNo

Have you ever been arrested? (DWI, bad checks, assault, etc.) YesNo
    What for?    Did you receive a fine/sentence? YesNo

Have you been a battered person? YesNo   When?

Have you served any time in jail?   YesNo   How Long?

Do you have any pending tickets? (speeding, parking, etc.) YesNo
    What for?   When is your court date?

Are you on parole or probation at present? Yes No   How long?
    Parole/Probation officer:    Phone Number:

Is there a warrant/s out for your arrest at present? Yes No
    Reason:

CO-APPLICANT PERSONAL HISTORY:
Age:    Social Security Number:    Date of Birth:
Location of Birth:
Married   Single   Divorced   Separated   Widowed     Previous marriages? Yes No


Education
Level: (select one)     School Grade Average (select one)

Name of School Year Graduated
High School/GED
College


Job History Information (Last 5 Years):
Year Company Name Pay Rate Duties Reason for Leaving


Family
Parents Names Address (city, state) Phone


Brothers/Sisters Names Address (city, state) Phone


Do you smoke? Yes No    How much per day?

Do you use drugs or alcohol? Yes No

Ever been in drug or alcohol rehabilitation? Yes No
    If yes, when:    Name of abused substance:
    Facility:    AA Participant? YesNo    NA Participant? YesNo

Have you ever been arrested? (DWI, bad checks, assault, etc.) YesNo
    What for?    Did you receive a fine/sentence? YesNo

Have you been a battered person? YesNo   When?

Have you served any time in jail?   YesNo   How Long?

Do you have any pending tickets? (speeding, parking, etc.) YesNo
    What for?   When is your court date?

Are you on parole or probation at present? Yes No   How long?
    Parole/Probation officer:    Phone Number:

Is there a warrant/s out for your arrest at present? Yes No
    Reason:


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. 

  1. No illegal activity of any kind will be permitted
  2. Use or possession of alcohol or illegal drugs is prohibited.
  3. 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.
  4. No overnight guests are allowed unless permission is obtained through a staff member.
  5. Children under the age of 13 must be attended by an approved adult at all times.
  6. Children must be enrolled in the school district nearest Hillcrest or in the district your family originates from. They must attend school everyday required..
  7. No fighting of any kind will be tolerated.
  8. No pets of any kind will be allowed.
  9. Smoking is NOT permitted inside the shelter units, buildings, or offices.
  10. Clients must keep shelter units & common areas clean and neat.
  11. All adults in the Hillcrest program are expected to work at least 40 hours per week.
  12. All adults must attend scheduled meetings & appointments.
  13. A $100 program deposit will be taken at time of shelter entry, or at time of first paycheck.
  14. 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.
  15. 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.


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