Foster Heritage Community Living Application Form Download Form SECTION 1 - PERSONAL INFORMATION Applicant Name * First Name Last Name Applicant Address What is your last known address? Address 1 Address 2 City State/Province Zip/Postal Code Country Applicant Email * Applicant Phone Number * (###) ### #### Applicant Gender * Male Female Applicant Race Black/African American Hispanic Asian White Other Applicant Language * Do you speak English? Yes No Applicant Marital Status * Single Married Divorced Widowed Other SECTION 2 - LIVING HISTORY Where have you lived in the last 30 days? * Select "Other" if more than one apply, then list all that apply. At the address listed in Section 1 Personal home/apartment Motel/hotel Lived with friends or family Hospital Emergency shelter Psychiatric facility Other Do you receive financial aid for housing assistance? * Yes No Have you ever been evicted? * Yes No What is your employment status? * Employed Unemployed Retired Other SECTION 3 - CRIMINAL HISTORY Have you ever been arrested, or convicted of a crime? * Yes No Do you have any criminal charges pending? * Yes No SECTION 4 - MEDICAL HISTORY Who is your Primary Care Physician (PCP)? (if available) Enter your PCP's phone number: Do you have any diagnosed medical illnesses? * Yes No Do you have allergies to medication, food or environmental? * Yes No Do you have any disabilities? * Yes No Do you have a history of substance abuse? * Yes No Do you have an history of mental illness? * Yes No SECTION 5 - ACTIVITIES OF DAILY LIVING (ADLs) Are you able to walk or move around independently? * Yes No Which of the following activities of daily living do you have difficulty with? * Select all that apply. Hygiene Taking medication as prescribed Meal preparation House keeping Money management Use of health services Securing/maintaining benefits Filling prescriptions None of the above SECTION 7 - EMERGENCY CONTACT Primary Emergency Contact Name First Name Last Name Relationship to Primary Contact Primary Emergency Contact Phone (###) ### #### Primary Emergency Contact Email AGREEMENT By submitting this form, I agree that the information I provided is true and complete to the best of my knowledge, and I understand that falsification or omission of information may result in denial of my application. Your application is currently being reviewed and we will contact you as soon as possible.Thank you!
