Application for Transitional Housing – Family & Adult

- GENERAL INFORMATION
- Please select your first choice of housing location.*
  - Independence
  - Lee's Summit
  - Kansas City, KS
  - Overland Park, KS
- If you want to be considered for mutiple housing sites, enter an Alternate Location(s) from the choices below:
- 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):
- Address
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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?
- 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 number from 1 to 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
- Please select the average grade you earned during your education.

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?
  MM slash DD slash YYYY
- 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 number from 1 to 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
- Please select the average grade co-applicant earned during their education

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?
  MM slash DD slash YYYY
- 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 & CaseWorthy 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.

Phone
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Application for Transitional Housing – Family Program

Family Program Application

Step 1 of 11

GENERAL INFORMATION

CURRENT LIVING ARRANGEMENT

HOUSEHOLD INFORMATION

HOUSEHOLD EXPENSES

HOUSEHOLD INCOME

SOCIAL SERVICES

MEDICAL AND COUNSELING SERVICES

TRANSPORTATION INFORMATION

PERSONAL HISTORY

CO-APPLICANT PERSONAL HISTORY

Programs Rules

Hillcrest Gets Results "Addressing the total life situation of the homeless clients we serve"