Please complete this form to be added to the Independent Worry-Free Living waitlist. All information will be kept confidential. A program representative will contact you once a placement becomes available.

Full Name: _________________________________

Date of Birth (MM/DD/YYYY): __________________

Phone Number: ______________________________

Email Address: ______________________________

Current Address: ____________________________

☐ Veteran

☐ Senior (age 60+)

☐ Individual experiencing homelessness

☐ Survivor of domestic violence

☐ Returning citizen (reentry)

☐ Low-income individual/family

Please briefly describe your current situation and housing needs:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Full Name: _________________________________

Relationship: ______________________________

Phone Number: ______________________________

I certify that the information provided is true and accurate to the best of my knowledge.

Signature: ___________________________ Date: _____________