Application - Where every one receives a second chance!

Name

Last Name

Email

Phone

Agency Affiliation(Required)

Birth Date(Required)

Age (Required)

Marital Status

Race

Are You a Veteran?

Yes

No

Do You Have an ID Card? (Driver's License or State ID)

Yes

No

Do You Have a SS Card?

Yes

No

Working

Yes

No

DOC Housing Voucher

Yes

No

SSI

Yes

No

SSDI

Yes

No

Other Income

HEALTH CARE

Medicaid

Yes

No

Both

Yes

No

Other

Yes

No

Please provide information about any medications here.

HAVE YOU LIVED IN SHARED HOUSING

Have you ever lost housing?

Do you have any debt or Legal Financial Obligations? (Required)

Other

INCARCERATION OR ARRESTS

Any charges pending?(Required)

Charge

County

Status

Charge

County

Status

DOC Number

What organizations help you or case managers providing resources?

WORK HISTORY

Are you working or looking for work?

Do you plan on school or training and what type of training?

What are your goals and plans?

Perkins Homes Foundation requires random urinalysis tests in the house and as a condition to entry to the house and remaining in the program. We do not require access to medical information, unless there is an emergency in the house, Or you are on medication prescribed by a physician or on a medically assisted treatment for addiction. Please initial where indicated.

Initials Here(Required)

1.2 Access to Medical Records and Other Personal Information: The Client hereby allows physicians and psychiatrists who have treated the Client, and all other providers of health care, including hospitals, to release to the Perkins Homes Foundation information needed for medically assisted treatment as needed for supportive housing. With respect to the Perkins Homes Foundation only, the Client hereby waives all privileges attached to the physician patient relationship and to any communication, verbal or written, arising out of such a relationship. The Perkins Homes Foundation is authorized to request, receive and review any information, verbal or written, pertaining to the Client’s physical or mental health, including medical and hospital records, and to execute any releases, waivers or other documents that may be required in order to obtain such information, and to disclose such information to such persons, organizations and health care providers as the Perkins Homes Foundation may designate.

Client Name(Required)

PHOTO CONSENT FORM

I, the undersigned, of legal age, hereby irrevocably grant to PERKINS HOMES FOUNDATION its subsidiaries, affiliates, agents, licensees, successors and assigns thereof (hereinafter referred to as “Company”), claiming under or through same, the following rights to use the materials and/or items described herein in any fashion, form, or media, whether currently in existence or hereinafter devised:

1. The right to photograph, record, videotape, store, and use the undersigned’s name, voice, appearance, likeness, signature and/or written testimony or statement along with any material furnished by me, in whole or in part, in any training, training materials and/or advertising materials produced, used or provided by Company, its subsidiaries, affiliates, agents, licensees, successors and assigns thereof, through means of mass, digital, and/or electronic media, including but not limited to printed, radio and television, promotional materials or events, and/or marketing plan, the Internet, and any other media and for all other types of advertising, publicity, promotion and other trade purposes for Company, its products and services;

2) The right to publish, text, exhibit, distribute and use the written or recorded testimonial or statement, or any parts thereof, my likeness and image, which shall appear as follows: first name and surname, general location of residence, and, where applicable, accompanied by photographs and/or recordings and/or signature, for commercial and/or non-commercial purposes, including but not limited to the advertising or solicitation of purchases, anywhere in the world where Company conducts business or intends to conduct business. I, the undersigned, hereby grant Company full ownership of and complete interest in any copyright I may have with regard to any written statement or other tangibly-fixed expression, which I have provided. I, the undersigned, hereby release and agree to indemnify and hold harmless Company, its subsidiaries, affiliates, officers, directors, agents, owners, employees, successors and assigns thereof, from any and all claims, actions, causes of action, damages, expenses, courts costs, attorney fees, liability damage or judgment suffered by the undersigned regarding the undersigned’s participation in or testimonial furnished by the undersigned to Company. I, the undersigned, hereby acknowledge that I have not been paid or otherwise compensated for the rights granted above. I further certify that all material, whether verbal, written or exhibited by me is not scripted or coached and represents my individual opinions and beliefs, and are true and correct to the best of the my knowledge. I, the undersigned, hereby acknowledge that I have read this document and understand its contents. I further acknowledge that I have executed this document voluntarily

Client Name(Required)

EMERGENCY CONTACTS (FAMILY OR FRIENDS)

Name

Field Name

Relation

Address

Field Name

Anything else we should know about you?

Additional Emergency Contact

Field Name

Relation

Address

Field Name

State / Province / Region

Field Name

Phone

Do you have children and what are their ages?

Counselor

Resident Signature(Required)

Preliminary Application