Young Adult (18-24) Housing Program Hillcrest of Platte County Young Adult Application Step 1 of 10 10% Applicant Full Name*FirstMiddle (required)Last Applicant Social Security*Applicant Date of Birth* Phone Number*Email Facebook Name* Current HousingWhere are you living right now?*FriendsRelativesHotelShelterCarStreetCurrent Address*How long have you been staying there?*Have you been asked to leave your current situation?*YesNoHow long can you stay there?*What kind of transportation do you have? Car Bus Bicycle Rely on others Have you ever lived at Hillcrest before?*YesNoWho referred you to Hillcrest?*Have you ever been in foster care? If yes, for how long?*Have you ever been in any other independent living program?* Yes No EmploymentAre you currently working?*YesNo Employment (continued)Company Name*Employment Start Date* Pay Rate*Second Job, Company Name (if any)Second Job, Employment Start Date Second Job, Pay Rate*Highest Grade of Education Completed*8th or less9th10th11th12thSome CollegeCollege GraduateDo you have a Diploma or GED?* OccupancyList all who would be living in the apartment (including yourself):Occupant List (List yourself and any children who will live with you):*NameAgeDate of BirthRelationshipSchoolRace (optional)Gender (optional) Is anyone pregnant?*YesNoWhat is the due date?* DebtList all debt:Payday/Title Loans:*Payday/Title Loans Past Due?*YesNoPast Due Debt: (utilities, evictions, credit cards)Type of DebtAmount Monthly BillsMonthly Recurring Bills:Type of BillAmount Please explain the reason for your situation:* MedicalHave you ever been a victim of domestic violence?*YesNoWhen?*Do you or any of family members living with you receive any medical or counseling services?*YesNoMedical or Counseling Services Listing:*NameProblemMedication Have you ever been in drug or alcohol rehab?*YesNoWhen?*Facility Name:*Name of substance abused* LegalHave you ever been arrested?*YesNoFor what?*Did you receive a fine or sentence?*Yes, a fineYes, a sentenceNoHave you been incarcerated?*YesNoIncarceration Beginning and End Dates*Are you on probation?*YesNoName of caseworker and contact information*Are you on parole?*YesNoName of parole officer and contact information* Young Adult Housing Program Rules: 1. No pets are allowed on the premises of any Hillcrest property. 2. No smoking is allowed in any apartment, including vapor. 3. Alcohol and drug use is forbidden while in the program. We reserve the right to conduct random drug screening/searches and if drugs or alcohol are found in your system or your apartment, or you are caught using these substances, you will be required to have a drug and alcohol assessment and/or attend treatment. You may also be asked to leave the program immediately. 4. Do not burn candles or incense in your apartment, as these present a fire hazard. 5. Participants are required to complete weekly chores. Assigned chores will be checked by House Parent 6. Weekly apartment checks will be conducted by House Parent, and will be announced and unannounced. 7. Participants are expected to clean up after themselves, wash their own dishes, and pick up their belongings. Staff retains the right to enter any apartment without notice. 8. Participants should NOT allow anyone into the building that they do not know. If a visitor claims to know another resident or staff person, leave the visitor outside and go find the resident or staff person to let them know that their visitor has arrived. If you see an unaccompanied visitor in the building, find a staff person immediately. 9. Participants owning a vehicle must have a valid driver’s license, a current vehicle registration, and auto insurance. 10. Aggressive, violent, threatening, or bullying behavior towards anyone will not be tolerated and could result in discharge from the program. Participants are expected to display respectful behavior towards staff and other participants. 11. Stealing from HPC or other participant’s money or property will not be tolerated and will result in discharge. I have read and understand that if I violate any one of these rules I may be dismissed from the Hillcrest program. I agree to hold Hillcrest Platte County and/or any other parties associated with this program in any way whatsoever, singly, or collectively, from any blame or liability for injury, misadventure, harm, loss, inconvenience, or damage suffered or sustained as a result of participation in this program or in activities associated therewith. I give permission for information to be released about me and my children, by or to any doctor, social worker, counselor, employer, landlord, shelter, agency, Rosie HMIS databases, or any other person deemed necessary by Hillcrest Platte County. I agree that my acceptance into the Hillcrest Platte County is not a rental agreement, and that this is not a landlord/tenant agreement, but an application for temporary homeless shelter & supportive services provided by the Hillcrest program. Any personal property of program Participants remaining on Hillcrest property after termination of contract for any reason will be deemed abandoned by the Participant and disposed of without further notice.MAACLink Client Consent and Release of Information MAACLink is a computer system that is used locally as a Homeless Management Information System (HMIS). Use of an HMIS is required by the US Department of Housing and Urban Development (HUD) for agencies that receive HUD funding. MAACLink is not electronically connected to HUD and is only used by authorized agencies. All MAACLink users have received confidentiality training and have signed strict agreements to protect clients’ personal information and limit its use appropriately. A Privacy Notice is available at participating agencies. It provides details on how member agencies and their employees handle client information and data sharing. I give permission to Hillcrest Platte County to collect and enter my personal and household information into the MAACLink computer system. I understand that the MAACLink system is shared with and used by authorized agencies in my community for the purposes of: 1. Assessing the needs of low-income, homeless or other people with special needs in order to give better assistance and to improve their current or future situations. 2. Improving the quality of care and service for people in need. 3. Tracking the effectiveness of community efforts to meet the needs of people who have received assistance. 4. Reporting data on an aggregate level that does not identify specific people or their personal information. I understand that: • All agencies that use MAACLink will treat my information in a professional and confidential manner. • Signing this release form does not guarantee that I will receive assistance. • My information may be shared with a third party (utility provider, landlord, etc) in order to process the service I have requested. • I have the right to a printed copy of my MAACLink file. Is all information you have provided on this form true and correct?YesNoNameThis field is for validation purposes and should be left unchanged.
