Application Please complete the following application to help us assess your eligibility for our housing program. All information provided is confidential.If you’d rather fill out a hard copy, you can download it in the box to the right. Downloadable Form Personal Information Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Gender * Male Female Prefer not to answer Best way to contact you? * Phone Email Text Bedroom Type Can you live in a shared environment with other independent individuals? * Yes No Preferred Room Type * Private Private Suite Semi Private Semi Private Suite Can you live in a shared space with 24/7 surveillance? * Yes No 24/7 Surveillance cameras in common areas: Is that ok with you? * Yes No When are you looking to move from your current environment? Health / Medical History Please List any medical diagnosis you may have * Independent Living Readiness Can you perform your own Activities of Daily Living (ADLs) (e.g., bathing, dressing, cooking ,ambulating, toileting )? * Yes No Do you require assistance with any ADLs? * Yes No (Note: We do not provide medical care or ADL assistance. All residents must be functionally independent.) Can you climb steps? * Yes No Do you need home care services? * Yes No Daily Living & Compatibility Are you okay with shared responsibilities such as cleaning common areas and respecting quiet hours? * Yes No How do you typically handle conflict with others? * Do you have any pets? * Yes No Are you okay living with pets (if the house permits them)? * Yes No Personal Background & Safety Have you ever been evicted or asked to leave a housing program? * Yes No Do you have any criminal history we should be aware of? * We will consider criminal history through a fair, individualized process Yes No Are you currently on probation or parole? * Yes No Personal Goals and Lifestyle What are you main goals for living in this housing program? (examples: saving money, building independence, recovery, stability, education/job goals) * How long do you anticipate staying with us? * Program Agreement & Policies Are you able to adhere to all house rules associated with this program? * Yes No Madison Rose Solutions maintains a No-Tolerance Policy for violating house rules. Do you agree to comply? * Yes No Do you understand that Madison Rose Solutions is not an assisted living facility and does not provide medical or personal care services? * Yes No Authorization & Signature I certify that all information provided is accurate. I understand that submitting this application does not guarantee placement and that Madison Rose Solutions reserves the right to evaluate eligibility. Submitting this form is your electronic signature. Thank you! Thank you!
