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Admission Forms

Admission Application/Assessment

Name *

First

Middle

Last

Date of Application *

Please enter in MM/DD/YYYY format.

Marital Status *

Single
Married
Separated
Divorced

If married, list Maiden Name

Driver's License/ ID Number *

Current Age *

Date of Birth *

Please enter in MM/DD/YYYY format.

S.S. # *

Enter in ###-##-#### format.

Primary Contact # *

Secondary Contact #

Email Address *

Please explain why you are seeking shelter at Hosea’s House? *

Do you have children? *

Yes
No

If yes, please list the names, sex, ages and birthdates of each minor child.

Do you have custody of all children listed above?

Yes
No

If no, please list name(s) of custodial parent/guardian

What relation is the custodial parent/guardian to applicant

Are you currently in a relationship? *

Yes
No

If yes, please describe status of relationship

Are you currently employed? *

Yes
No

If yes, list name and address of employment

Are you employed

Full time
Part-time

Hours Per Week

Weekly Income

Bi-weekly Income

Monthly Income

If you are not employed, why?

When was your last date of employment?

What type of work?

If not employed, please list all forms of income for household:

Food Stamps, K-TAP, SSI/SSDI, Other, Child Support, K-Chip, or Unemployment, and amount you get monthly.

Did you graduate from high school? *

Yes
No

If no, highest Grade completed

Have you attended college? *

Yes
No

Degree

Technical Training

Have you ever live in subsidized (income-based) housing? *

Yes
No

If yes, where? (city/state)

List address for last residence *

Have you ever been evicted? *

Yes
No

Do you have any outstanding balances with landlords? *

Yes
No

If yes, how much do you owe?

Do you own or have access to a vehicle? *

Yes
No

If yes, please list make/model of vehicle

License plate #

Color

If no vehicle, please list other forms of transportation (public, friend, family, etc.)

Do you have any past or pending criminal charges? *

Yes
No

Do you have a felony charge? *

Yes
No

If yes, what is/are the charge(s)?

Have you ever been turned down for housing/employment because of your criminal background? *

Yes
No

Are you required to register as a sex offender? *

Yes
No

Have you had treatment in the past for substance and/or alcohol abuse? *

Yes
No

Are you currently in treatment? *

Yes
No

If yes, list dates of treatment

Please list current/ most recent Program or Treatment Facility

How long have you been drug and/or alcohol free? *

Please put in Years, Months, or Days. i.e. 5 days/months/years

Has alcohol or substance abuse affected your ability to work? *

Yes
No

What is your religious background? *

Do you attend church? *

Yes
No

If yes, how often?

Rarely
Sometimes
Regular

Applicant’s Signature *

First

Last

Date *

Your plan of action (goals) is designed specifically for you and your family’s needs. Your action steps are things you need to do to accomplish your goals. *

What do you hope to accomplish during your stay with us at Hosea’s House? Please list at least 3 items and list them in order of importance to help you reach self sufficiency

What steps are needed to accomplish each goal listed above? *

Goal 2

Goal 3

Applicant's Signature *

First

Last

Date *

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