RESIDENTIAL APPLICATION

RESIDENTIAL APPLICATION

Two Sparrows Village at Christian City Cottage & Suites
Please complete digitally using Acrobat Reader, or manually by printing and completing, and return via email or postal service at the address on the last page.
Date

MonthDayYear
Date
Person completing application
Relationship to Applicant
APPLICANT INFORMATION
Name: Last
First
Middle
Preferred Name
Current Address

Current Address

Street Address Line 2

CityState / Province

Zip
Zip
Home Phone Number
Cell Phone Number

Area CodePhone Number
E-Mail
example@example.com
Permanent Address

Permanent Address

Street Address Line 2

CityState / Province

Zip
Birth Date

MonthDayYear
Date
Age
Please complete all applicable questions. Emergency Contact Name:

EMERGENCY CONTACTS, and their relationship to you (e.g., mother, father, grandparent, sibling):
First Contact's Name
Relationship to you
Home Phone Number
Cell Phone Number
Please enter a valid phone number.
E-Mail Address
example@example.com
Alternate E-Mail Address
example@example.com
Second Contact’s Name
Relationship to you
Home Phone Number
Cell Phone Number
Please enter a valid phone number.
E-Mail Address
example@example.com
Alternate E-Mail Address
example@example.com
Name of Conservator or Power of Attorney (POA)
Home Phone Number
Cell Phone Number
Please enter a valid phone number.
E-Mail Address
example@example.com
Alternate E-Mail Address
example@example.com
CRIMINAL BACKGROUND CHECK
Due to the Federal funding received by Christian City, we are prohibited from offering housing to any residents with a criminal record (of any kind Part of your application with Two Sparrows Village at Christian City will include a criminal background check.
LANDLORD VERIFICATION
Yes, attached is my landlord verification.
File Upload

Cancelof
EDUCATION
Finished high school?

NoYes
If yes, Regular or IEP Diploma?
Name of School
Year Graduated
Any post-secondary education?
Finished high school?

NoYes
If yes, Name of School
Year
Additional education/training
Additional education/training
Page 1, Two Sparrows Village Application
EMPLOYMENT
Are you employed?

NoYes
If yes, part-time or full-time?
Where do you work?
What position do you have?
Have you worked there for over one year?

NoYes
If no, where have you worked previously?
Do you volunteer?

NoYes
If yes, where do you volunteer and what do you do?
If yes, where else do you volunteer and what do you do?
OPTIONAL ADDITIONAL INFORMATION
Medical Doctor
Phone
Dentist
Phone
Other Doctors (i.e., podiatrist, cardiologist, psychologist)
Name
Type Healthcare Practice
Phone
Name
Type Healthcare Practice
Phone
Name
Type Healthcare Practice
Phone
What is the applicant’s I/DD diagnosis?
Does the applicant take medicine? Yes
Does the applicant take medicine?

NoYes
If yes, please list all prescription and over the counter drugs currently used
If yes, please list all prescription and over the counter drugs currently used
Can the applicant take the medications without assistance? Yes
Can the applicant take the medications without assistance?

NoYes
Does the applicant need supervision in taking medicines?

NoYes
If yes, which medicine(s) does the applicant need supervision in taking medicines?
SPECIAL INTERESTS
Do you have any special needs that you would like us to know about?
Do you have any special interests that you would like us to know about?
TRANSPORTATION
Does the applicant have a driver’s license?

YesNo
Can the applicant use public transportation? Yes
If yes, upload a copy of applicant's driver's license.

Cancelof
If yes, upload a copy of applicant's auto insurance card.

Cancelof
Can the applicant use public transportation?

NoYesNeeds training on use of public transportation
What specific transportation needs does the applicant have?
Page 2, Two Sparrows Village Application
OPTIONAL
Please provide the names, addresses, and phone numbers of three persons who can provide letters of reference.
Reference 1: Name
Relationship to applicant
Address
Phone
Email
example@example.com
Reference 2: Name
Relationship to applicant
Address
Phone
Email
example@example.com
Reference 3: Name
Relationship to applicant
Address
Phone
Email
example@example.com
Your signature below will release the Two Sparrows Village Assessment Team and the above listed Contact Persons to openly confer and share the information regarding the above applicant.
Applicant's Name (Print)
Signature

Clear
Date

MonthDayYear
Date
Two Sparrows Village is a shared living experience, where you share a house/cottage with older adults, a few students (from local colleges/universities) and some other individuals with developmental and/or intellectual disabilities.
You would be living in community with these other individuals. Is living in community with others something you would like to do?

NoYes
What does living in community with others mean to you?
What do you hope to gain as a resident in the Two Sparrows Village at Christian City community?
What do you hope to give as a resident in the Two Sparrows Village at Christian City community?
Page 3, Two Sparrows Village Application
APPLICANT’S SIGNATURE
I certify that the content of this application is true. I understand that the penalty for knowingly providing false information is up to five (5) years in prison and/or up to a $10,000 fine upon conviction.
Applicant Signature
Date

MonthDayYear
Date
Print Name
GUARANTOR’S SIGNATURE
I certify that the content of this application is true. I understand that the penalty for knowingly providing false information is up to five (5) years in prison and/or up to a $10,000 fine upon conviction.
Guarantor’s Signature
Date

MonthDayYear
Date
Print Name
Relationship to Applicant
It is the policy of this company to provide housing on an Equal Opportunity basis. We do not discriminate on the basis of race, religion, color, sex, familial status, national origin or handicap.
STEPS TO COMPLETION
There are several steps to applying to live in Two Sparrows Village at Christian City. They are: 1) Complete this Two Sparrows Village application form. 2) There is a two-week turnaround by Two Sparrows Village at Christian City. Once your application is approved, you will be asked to pay Two Sparrows Village a non-refundable turn fee of $100. There is no security deposit. Rent, which is paid by money order or ACH to Two Sparrows Village, includes apartment rental with utilities ($1,200), WiFi ($25), and Activities ($275) per month. 3) Your total up-front fee is $160.00 and the entire process should take 2-3 weeks. 4) We encourage you to participate in 3-5 days in our Two Sparrows Village day program.

Please return this application and certified application fees of $160 to:

Jacque Thornton, Executive Director Two Sparrows Village, Inc. 805 Glynn St., South; Suite 127-316; Fayetteville, GA 30214

or email to: Jacque@TwoSparrowsVillage.org

Your contact at Christian City will be announced if you become a resident.
7345 Red Oak Road, Union City, GA 30291
or
Page 4, Two Sparrows Village Application
Should be Empty:

RESIDENTIAL APPLICATION

APPLICANT INFORMATION

CRIMINAL BACKGROUND CHECK

LANDLORD VERIFICATION

EDUCATION

EMPLOYMENT

OPTIONAL ADDITIONAL INFORMATION

SPECIAL INTERESTS

TRANSPORTATION

OPTIONAL

APPLICANT’S SIGNATURE

GUARANTOR’S SIGNATURE

STEPS TO COMPLETION