Chautauqua Opportunities, Inc



Chautauqua Opportunities, Inc.

Luke’s Place

Transitional Independent Living Program

Application

Name _________________________________________________ Date ___________

Date of Birth___________________________________________ Age_____________

Current Address_________________________________________________________

Current Phone Number____________________________________________________

Email Address___________________________________________________________

Current Living Situation:

Who do you live with now? __________________________________________

Do you have an immediate need for emergency shelter? ___________________

Have you ever rented an apartment on your own? ________________________

Education:

Are you currently enrolled in school? ___________________________________

If yes, what school do you attend? _____________________________________

What grade are you in right now?______________________________________

Are you a High School graduate? ______________________________________

Employment:

Are you currently employed? _________________________________________

If yes, please provide your employer’s name, address, and phone number.

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

How many hours do you work per week? ________________________________

If you are not currently employed, are you legal to work in the United States?___

__________________________________________________________________

Financial Information:

Banking: Do you have a checking or savings account?______________________

If yes, please provide the name of your bank? ______________________

Income: Do you get money from any of the following sources?

Public Assistance_____

Social Security (SSI or SSD)_____

Child Support____

Other Source____ Please Explain_________________________________

Other Resources: Food Stamps_____

Medicaid____

Any Other Resources____ Please Explain____________________

Health History:

Do you have any current health issues?__________________________________

Are you taking any medication for this?__________________________________

Please list your medications:___________________________________________

Do you have any past health issues that we need to be aware of?_____________

__________________________________________________________________

Legal History:

Have you ever been arrested and/or convicted of a crime? _____________

If yes, please explain___________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Are you currently in trouble with the law? _______________________________

If yes, please explain __________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Are you currently on probation? _______________________________________

*Please note that past or current criminal history does not necessarily disqualify you from being considered for admittance to the TILP program.

In our effort to provide you with the most effective case management services, please provide information for any other service providers you are currently working with. Examples include SPOA, DSS, CPS, etc.

Agency_________________________________________________________________

Contact Person___________________________________________________________

Phone Number___________________________________________________________

Agency_________________________________________________________________

Contact Person___________________________________________________________

Phone Number___________________________________________________________

Agency_________________________________________________________________

Contact Person___________________________________________________________

Phone Number___________________________________________________________

Agency_________________________________________________________________

Contact Person___________________________________________________________

Phone Number___________________________________________________________

Please list the Independent Living skills you expect to learn from this program:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Explain why you are interested in the TILP program:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe any alternative living arrangements you currently have if you are not accepted into TILP, or if you are placed on our waiting list:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What else would you like us to know about you?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

References:

When providing your references, please make sure the contact information is current. You may not be considered for this program if we are not able to contact your references.

Name___________________________________________________________________

Address_________________________________________________________________

Phone Number___________________________________________________________

Name___________________________________________________________________

Address_________________________________________________________________

Phone Number___________________________________________________________

Name___________________________________________________________________

Address_________________________________________________________________

Phone Number___________________________________________________________

Name___________________________________________________________________

Address_________________________________________________________________

Phone Number___________________________________________________________

The above information, to the best of my knowledge, is true and correct.

__________________________________________________________ ____________

Signature Date

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