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.

Applicant Information

Full Name: Date of Birth: Email Address: Phone Number: Gender:
Male Female Prefer not to answer

Best way to contact you:
Phone Email Text

Bedroom Type

Can you live in a shared environment?
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

Is 24/7 surveillance in common areas okay?
Yes No

When are you looking to move?

Health / Medical History

Please list any medical diagnosis:

Independent Living Readiness

Can you perform your own ADLs?
Yes No

Do you require assistance with any ADLs?
Yes No
If yes, select:
Bathing Dressing Ambulating Cooking Toileting

Can you climb steps?
Yes No

Do you need home care services?
Yes No

Daily Living & Compatibility

Are you okay with shared responsibilities (cleaning, quiet hours)?
Yes No

How do you typically handle conflict? Do you have any pets?
Yes No

If yes, how many? Are you okay living with pets (if permitted)?
Yes No

Personal Background & Safety

Have you ever been evicted or asked to leave a housing program?
Yes No

If yes, explain: Do you have any criminal history?
Yes No

Are you currently on probation or parole?
Yes No

Personal Goals & Lifestyle

Main goals for living in this housing program: How long do you anticipate staying?

Program Agreement & Policies

Can you adhere to all house rules?
Yes No

Do you agree to the No-Tolerance Policy?
Yes No

Do you understand this is not an assisted living facility?
Yes No

Authorization

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.

Applicant Signature: Date: