• 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

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  • II. ACADEMY ENROLLMENT REQUIREMENTS

  • III. GENERAL OVERVIEW

    Tell us more about you
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  • 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

  • V. MEDICAL INFORMATION & HISTORY

  • 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

  • VII. LEGAL HISTORY


  • If yes, who?     Date:   Pick a Date    
    Details:    

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  • VII. FAMILY, HOUSING & HOUSEHOLD

  • -Last Name First Name Social Security No.     Date of Birth   Pick a Date    

  • -Last Name First Name Social Security No.     Date of Birth   Pick a Date    

  • -Last Name First Name Social Security No.     Date of Birth   Pick a Date    

  • -Last Name First Name Social Security No.     Date of Birth   Pick a Date    

  • -Last Name First Name Social Security No.     Date of Birth   Pick a Date    

  • -Last Name First Name Social Security No.     Date of Birth   Pick a Date    

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    Pick a Date
  • Where did you sleep last night? * City: *

  • Where did you sleep last week? * City: *

  • Please provide 5 years of Rental History

  • Current or previous landlord: Apt. #             
    Name of Complex:      
    Current Landlord Name:            
    Monthly Rent: $      Reason for Leaving:      

  • DEPENDENTS (Fill out for each child)

  • Name: * Age: *  
    Attend School Regularly?   *   Grade:   *  
    Attend childcare regularly?    *   If yes, what hours?   *   
    School:   *   Childcare:   *   
    Last Attended:   *   
    Medical Problems:   *   

  • Name: Age:   
    Attend School Regularly?      Grade:     
    Attend childcare regularly?       If yes, what hours?      
    School:      Childcare:      
    Last Attended:      
    Medical Problems:      

  • Name: Age:   
    Attend School Regularly?      Grade:     
    Attend childcare regularly?       If yes, what hours?      
    School:      Childcare:      
    Last Attended:      
    Medical Problems:      

  • Name: Age:   
    Attend School Regularly?      Grade:     
    Attend childcare regularly?       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                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • B. Employment Income 2                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • C. Social Security 1                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • D. SSI (Supplement) 1                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • E. Pension Retirement 1                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • F. Child Support Awarded                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • G. Alimony Awarded                  
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • H. Veteran's Benefits                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • I. Welfare/TANF                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • J. Unemployment 1                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • K. Workers Comp.                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • L. Interest Income                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • M. Scholarships/Grants                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • N. Monetary Gifts                  
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • O. Other Income                   
    Amount received (indicate week/month/year) $
    Received by which household member:
    Source of Income (Name/address/Phone)      

  • ^ Must include all monthly obligations, including medical expenses, car payments, child support, loans, etc.

  • X. EMPLOYMENT

  • Work Phone:         Date Started:   Pick a DateHours per week:      Hourly Wage: $   
    Status:                

  • Last 3 Employers
    Previous Employer:      Job Title:      
    Work Phone:         Date Started:   Pick a DateDate Left:   Pick a Date   Hours per week:      
    Hourly Wage: $   

  • Military Background?:              If yes, years of duty:      
    Describe years of service and branch of training:         
    Discharge status:     
    Education:  

  • EMERGENCY NOTIFICATION (OPTIONAL)

  • Person to notify in case of emergency:
    Name: Relationship:
    Phone:         Address:                  

  • 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,    Pick a Date*   will expire after a period of one year. I have a right to receive a copy of this authorization upon my request.

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  • 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.
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  • 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.

     

     

    ***Once your application is submitted, it is your responsibility to call our front desk (760) 941-6545 to schedule a screening appointment.

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