Solutions for Change Online Program Application

Application for Academy Admission

It is Solutions for Change’s policy to provide equal opportunity for all program applicants and program participants. Solutions for Change does not unlawfully discriminate on the basis of race, color, religion, sex (including pregnancy, childbirth or related medical conditions), national origin, ancestry, age, physical disability, mental disability, medical condition, family-care status, veteran status, marital status, gender, gender identity, gender expression, genetic information, familial status, immigration or citizenship status, perceived immigration or citizenship status or sexual orientation. Solutions for Change also makes reasonable accommodations for the disabled program participants. Finally, Solutions for Change prohibits the harassment of any individual on any of the bases listed above. This nondiscrimination policy applies to all areas of employment and program participation including recruitment, hiring, training, promotion, compensation, benefits, and social and recreational programs.
I. GENERAL INFORMATION
Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
II. ACADEMY ENROLLMENT REQUIREMENTS
In preparation for Solutions Academy, I am aware, prepared, and can meet the following requirements:

Yes, I am a parent with minor dependent children in my custody. If a couple, we are married or are both legal parents of our children as verified by a birth certificate. Yes, I will work full-time and I possess the legal documents to work in the United States. Yes, I will actively participate in the support services including coaching, education, workshops, classes, counseling, and (if needed) outpatient substance abuse treatment. Yes, I can maintain the appropriate behavior of all members of the household. Yes, I will ensure my children have care through either school and/or childcare Monday-Friday, 8am - 4:30pm. This is a requirement for successful completion of the program. Yes, if I have a mental health condition or diagnosis, I will take my prescribed medication and will treat my mental health/participate in counseling as needed. Yes, I can pass a drug test. Yes, I understand that this is not a "safe house." Note: If I am fleeing a recent domestic violence situation, I will be referred to a safe place and have the option to enter Solutions later. No, I do not have a criminal conviction for physically hurting other people, children, or destroying property.
III. GENERAL OVERVIEW

Tell us more about you
Do you have a history of addiction or alcoholism? *

Yes No
When is the last time you used drugs?

Month Day Year
Date
When is the last time you drank alcohol?

Month Day Year
Date
If yes, what drugs or alcohol?
Have you completed drug treatment? *

Yes No
Are you in the process of completing treatment? *

Yes No
Completion Date

Month Day Year
Date
Are you currently on methadone? *

Yes No
What medications are you currently taking?
Are you able to work without limitations? *

Yes No
Are you in the process of receiving disability/currently receiving disability? *

Yes No
Are you currently working? *

Yes No
Where?
How Long?
Pay/hour?
$/hr
Are you willing to quit your job to work our program?

Yes No
Are your children enrolled in school? *

Yes No
Are your school-age children enrolled in an afterschool program/daycare?

Yes No
Do you have childcare for children that are too young to attend school?

Yes No
Have you been diagnosed with a mental health disorder? *

Yes No
Diagnosis:
Are you currently seeing a psychiatrist or therapist? *

Yes No
Do you have children under the age of 18 in your custody? *

Yes No
Are you CWS involved? *

Yes No
Are your visits:

Supervised Unsupervised
Next court date?

Month Day Year
Date
Have you been convicted of any violent crimes? *

Yes No
Charges:
Have you ever hallucinated (saw/heard/felt something that wasn't there)? *

Yes No
Have you had suicidal thoughts? *

Yes No
When?
Are you currently pregnant? *

Yes No
Due Date

Month Day Year
Date
Is there a chance that you could be pregnant? *

Yes No
APPLICATION AMENDMENT

The information on this application is requested by Solutions for Change in order to assure the Federal Government, acting through its agencies that Federal Laws prohibiting discrimination against tenant applicants on the grounds of race, color, creed, national origin, religion, sex, marital or familial status, age, or physical or mental handicap are complied with. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, Solutions for Change is required to note the race/national origin and sex of individual applicants on the basis of visual observation or surname.
IV. DEMOGRAPHICS
Ethnicity: Please check what applies to you

Hispanic or Latino Non-Hispanic or Latino White African American Native American or Alaskan Native Asian and white Native Hawaiian or other Pacific Islander American Indian/Alaskan and Black African American and White Other
Gender: Please check what applies to you *

Male Female Transgender Other
V. MEDICAL INFORMATION & HISTORY
Do you consider yourself, or another family member as having a disability? *

Yes No
If yes, who has the disability?
Is the disability:

Permanent Temporary
What is the disability?

Physical Mental Developmental Chemical Dependency
Are you or any member of your family experiencing health problems? *

Yes No
If yes, who:
Describe:
Have you or any family member been hospitalized for any reasons related to mental health? *

Yes No
If yes, who:
Describe:
CURRENT MEDICATIONS (for all family members)
Person Taking:     Medication Name:
Prescribed By:      Prescribed For:
How long been taking?
Person Taking:     Medication Name:
Prescribed By:      Prescribed For:
How long been taking?
Person Taking:     Medication Name:
Prescribed By:      Prescribed For:
How long been taking?
Person Taking:     Medication Name:
Prescribed By:      Prescribed For:
How long been taking?
VI. DRUG/ALCOHOL HISTORY
Please describe any alcohol history:
Please describe any drug history:
Have you ever attended a 12-step meeting? *

Yes No
If yes, who?
What type?
Why?
VII. LEGAL HISTORY
Do you have a valid CDL? *

Yes No
If no, explain:
Have you ever been arrested and convicted of the following:

Domestic Assault Assault Arson Drugs Property Damage Robbery Possession Distribution/trafficking Any violent crime DUI
If convicted/arrested for a violent crime/DUI/other - please explain
If yes, who? Date: Date
Details:
Do you currently have any outstanding criminal justice issues? *

Yes No
If yes, please provide details:
Outstanding Warrants (explain below) Bail Violations (explain below) Outstanding Bail Conditions (explain below) Current Convictions, awaiting sentencing Sentencing obligations
Outstanding warrants/bail violations/outstanding bail conditions, please explain:
Have you ever been convicted of a misdemeanor? *

Yes No
If yes, who?
Explain:
Have you ever been convicted of a felony? *

Yes No
If yes, who?
Explain:
Are you on parole or probation? *

Yes No
If yes, please describe the terms of parole/probations:
Name of parole or probation officer?
Parole/Probation Officer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parole/Probation Officer Phone Number

Area Code Phone Number
Are there any legal and/or personal matters which could interfere with you completing your two year Academy program? *

Yes No
If yes, please explain:
VII. FAMILY, HOUSING & HOUSEHOLD
-Last Name blanks First Name blank Social Security No. Date of Birth Date
-Last Name blanks First Name blank Social Security No. Date of Birth Date
-Last Name blanks First Name blank Social Security No. Date of Birth Date
-Last Name blanks First Name blank Social Security No. Date of Birth Date
-Last Name blanks First Name blank Social Security No. Date of Birth Date
-Last Name blanks First Name blank Social Security No. Date of Birth Date
Have you or any other adult household occupant(s) used or been known by any other name and/or alias? *

Yes No
Please specify who and what other name(s) are/were used:
Residency Status: are all household members U.S. Citizens? *

Yes No
If NO, are all non-citizen household members legal residents? *

Yes No
Have any household members ever been evicted from any housing? *

Yes No
How many times?
Number of prior evictions when not on the lease?
Number of court ordered unlawful detainers? (Forcibly removed from housing):
Reasons for prior evictions:

Nonpayment of Rent Illegal Activity -drug related Domestic Violence Person in household not on lease Illegal Activity - not drug related Property Damage
Number of times you went to court to contest an eviction
Date of last eviction:

Month Day Year
Date
Does any member have any history of criminal activity within the last (7) years, including but not limited to, crimes of violence against persons or property, unlawful drug activity of any kind, or other acts adversely affecting the health, safety or welfare of others? *

Yes No
If yes, please explain:
Has any household member's rental assistance or tenancy in a subsidized housing program ever been terminated for fraud, nonpayment of rent, or failure to cooperate with the recertification procedures? *

Yes No
If yes, explain the circumstances:
Current Residence:

Emergency Shelter Temporary Shelter Hotel/Motel Family Friends/Living in Car/Living on the streets
Name of above residence:
Where did you sleep last night? blanks* City: blank*
Where did you sleep last week? blanks* City: blank*
Current living situation in detail:
What are the reasons for your homelessness?
How long have you been in this situation?
Have you ever been homeless before this time? *

Yes No
When?
Explain:
Please provide 5 years of Rental History
Current or previous landlord: blanks Apt. # blank   City   State   Zip
Name of Complex:
Current Landlord Name:      Area Code   Phone Number
Monthly Rent: $      Reason for Leaving:
DEPENDENTS (Fill out for each child)
Name: blanks* Age: blank*
Attend School Regularly? Yes  No*   Grade:   *
Attend childcare regularly? Yes   No*   If yes, what hours?   *
School:   *   Childcare:   *
Last Attended:   *
Medical Problems:   *
Name: blanks Age: blank
Attend School Regularly? Yes  No   Grade:
Attend childcare regularly? Yes   No   If yes, what hours?
School:      Childcare:
Last Attended:
Medical Problems:
Name: blanks Age: blank
Attend School Regularly? Yes  No   Grade:
Attend childcare regularly? Yes   No   If yes, what hours?
School:      Childcare:
Last Attended:
Medical Problems:
Name: blanks Age: blank
Attend School Regularly? Yes  No   Grade:
Attend childcare regularly? Yes   No   If yes, what hours?
School:      Childcare:
Last Attended:
Medical Problems:
IX: INCOME

Does any member of this household anticipate receiving income from any of the following sources? Complete all the blanks for any questions answered with yes. Note: You must list addresses of income sources. They will be used for verification.
A. Employment Income 1 Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
B. Employment Income 2 Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
C. Social Security 1 Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
D. SSI (Supplement) 1 Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
E. Pension Retirement 1 Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
F. Child Support Awarded Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
G. Alimony Awarded Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
H. Veteran's Benefits Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
I. Welfare/TANF Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
J. Unemployment 1 Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
K. Workers Comp. Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
L. Interest Income Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
M. Scholarships/Grants Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
N. Monetary Gifts Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
O. Other Income Yes No
Amount received (indicate week/month/year) $blanks
Received by which household member: blank
Source of Income (Name/address/Phone)
MONTHLY FINANCIAL OBLIGATIONS
^ Must include all monthly obligations, including medical expenses, car payments, child support, loans, etc.
VEHICLES - List any autos, motorcycles, boats, campers, motor homes, trailers, etc. belonging to anyone in your household.
X. EMPLOYMENT
Are you currently employed? *

Yes No
Current Employer
Job Title
Work Phone: Area Code Phone Number Date Started: DateHours per week: Hourly Wage: $
Status: Permanent Temporary Seasonal Part Time Full Time
Last 3 Employers
Previous Employer:      Job Title:
Work Phone:   Area Code   Phone Number   Date Started:   DateDate Left:   Date   Hours per week:
Hourly Wage: $
Military Background?:    Yes   No       If yes, years of duty:
Describe years of service and branch of training:
Discharge status:
Education:
Please take a moment and tell us about yourself in your own words. Anything you would like us to know about you, why you want to participate in our program, what would you like to get out of our program?
EMERGENCY NOTIFICATION (OPTIONAL)
Person to notify in case of emergency:
Name: blanks Relationship: blank
Phone: Area Code Phone Number Address: Street Address Address Line 2 City State Zip
HOUSING

NON-DISCRIMINATION STATEMENT: We are an Equal Housing Opportunity Provider. We provide rental housing without discrimination on the basis of race, color, creed, national origin, religion, sex, marital or familial status, age, orientation, income source, physical or mental handicap, or other protected classes as defined by the laws of the Federal or State government, either now in place or put in place at a later date.
HUD Guidelines - Homelessness
1. Any individual or family who lacks affixed regular and adequate nighttime residence. Meaning the individual:
  1. Lives on the street; lacks a fixed, regular, adequate nighttime residence; or lives in places not meant for human habitation; or
  2. Resides in a supervised publicly or privately operated shelter designated to provide temporary living arrangement that includes: congregate shelter, transitional housing, hotel or motel paid for by charitable organizations or by a unit of government for low-income individuals; or
  3. Is exiting an institution where he or she resided for 90 days or less and who lived in an emergency shelter or a place not meant for human habitation immediately before entering that institution.
2. An individual or family who will imminently lose their primary residence, provided they meet the following conditions:
  1. The primary nighttime residence will be lost within 14 days of the application for homeless assistance; and
  2. No subsequent residence has been identified; and
  3. The individual or family lacks the resources or support networks (family, friends, faith-based, or other social networks) needed to obtain other permanent housing.
3. For households with children: Unaccompanied youth under age 25, or families with children and youth who do not otherwise qualify as homeless under this definition, but who meet the following four conditions:
  1. Are defined as homeless under one of the following federal acts: Section 387 of the Runaway and Homeless Youth Act (42 USC 5732a); or section 637 of the Head Start Act (42 USC 9832); or section 14043 of the Violence Against Women Act (42USC 14013e-2); or section 330(h) Public Health Services Act (42USC 254 b); or section 3 of the Food and Nutrition Act of 2008 (7 USC 2012); or section 17(b) of the Child Nutrition Act of 1996 (42 USC 1786); or section 725 of the Mc Kinney-Vento Homeless Assistance Act (42 USC 11424 a); and
  2. Have not had a lease, ownership interest, or occupancy agreement at any time during the 60 days immediately prior to the date of application for homeless assistance; and
  3. Have experienced persistent housing instability as measured by two or
    more moves during the 60-day period immediately prior to the date of application for homeless assistance; and
  4. Are expected to continue in an instable status for an extended period of time because of chronic disabilities; chronic physical health or mental health conditions; substance addiction; history of domestic violence or child abuse (including neglect); the presence of a child or youth with a disability; or two or more barriers to employment, including a lack of a high school diploma or General Education Development certificate (GED), illiteracy, low English proficiency, a history of incarceration or detention for criminal activity, and a history of unstable employment.
4. Any family or individual who:
  1. Is fleeing, or attempting to flee, domestic violence, dating violence, sexual assault, stalking or other dangerous or life-threatening conditions that relate to violence against the individual or family member, including a child that has either occurred within the individual’s or family’s primary nighttime residence or has made the individual or family afraid to return to return to their primary nighttime residence; and
  2. Has no other residence; and
  3. Lacks the resources or support networks (family, friends, faith-based or other social networks) to obtain other permanent housing.
I understand that all the information given on this application is subject to verification, including a credit report and criminal background report. Any information determined to be false or untrue may result in the permanent cancellation of the application.
REASONABLE ACCOMODATION

This apartment community does not discriminate against applicants or residents on the basis of disability. In addition, we have a policy to provide “reasonable accommodations” to residents where possible. This may include priority for an accessible apartment of modifications to the apartment or premises.A reasonable accommodation is some modification or adjustment to income that we can make that will afford an otherwise eligible applicant or resident with a disability an equal opportunity to use and enjoy the apartment, including public and common use areas. An applicant household that has a member with a disability must still be able to meet essential obligations of the resident selection criteria. They must be able to pay rent on time. Care for their apartment, report required information to Management, avoid disturbing their neighbors, etc.; however; there is no requirement that they be able to do these things without assistance.If a member of your household has a disability and you think you might need or want a reasonable accommodation that relates to your disability, please ask the Property Manager for a Special Requirements Questionnaire form.
MEDICAL INFORMATION
I understand that my records are protected under the Federal Regulations governing the confidentiality of patient medical records (42 CFR, Part 2), and cannot be disclosed without written consent, unless otherwise provided for its regulations. This consent is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance on it, and, unless further limited by the date stated here, Date* will expire after a period of one year. I have a right to receive a copy of this authorization upon my request.
Participant Name *
Participant Signature *

Clear
DEMOGRAPHIC INFORMATION

The information on this application is requested by Solutions for Change in order to assure the Federal Government, acting through its agencies that Federal Laws prohibiting discrimination against tenant applicants on the grounds of race, color, creed, national origin, religion, sex, marital or familial status, age, or physical or mental handicap are complied with. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, Solutions for Change is required to note the race/national origin and sex of individual applicants on the basis of visual observation or surname.
Participant Name *
Participant Signature *

Clear
A portion of funding for Employee Related Training is provided by United States Department of Agriculture (USDA). USDA is an equal opportunity provider, Employer, and Lender.
Should be Empty:

Application for Academy Admission

I. GENERAL INFORMATION

II. ACADEMY ENROLLMENT REQUIREMENTS

III. GENERAL OVERVIEW

APPLICATION AMENDMENT

IV. DEMOGRAPHICS

V. MEDICAL INFORMATION & HISTORY

CURRENT MEDICATIONS (for all family members)

VI. DRUG/ALCOHOL HISTORY

VII. LEGAL HISTORY

VII. FAMILY, HOUSING & HOUSEHOLD

DEPENDENTS (Fill out for each child)

IX: INCOME

X. EMPLOYMENT

EMERGENCY NOTIFICATION (OPTIONAL)

HOUSING

HUD Guidelines - Homelessness

REASONABLE ACCOMODATION

MEDICAL INFORMATION

DEMOGRAPHIC INFORMATION