Jeremiah's Promise | Tenant Application

TENANT APPLICATION To be considered as a future Resident at a Jeremiah’s Promise home, you must complete ALL parts of the application. Please be assured that all personal information you share will be kept confidential and will be used only in determining your eligibility to move in. If you have any questions, feel free to call us at 408.962.0630 or email us at admissions@jeremiahspromise.org.
Today's Date	(mm/dd/yyyy)
First Name
Middle Name
Last Name
Address
Address Line 2
City
State
ZIP
Cell Phone	(xxx-xxx-xxxx)
Alternate Phone	(xxx-xxx-xxxx)
Email
Birthdate	(mm/dd/yyyy)
Social Security Number	(xxx-xx-xxxx)
Gender	Male Female
PLACEMENT INFORMATION
Foster Parent(s) Name(s) or Placement Name			How long have you been at your current placement?
			(yy/mm)
Please provide information regarding your last two placements (before your current placement) including how long you were there and a brief description of the reason you left.
Foster Parent(s) Name(s) or Placement Name			How long were you at this placement?
			(yy/mm)
What is the reason you left this placement?
Foster Parent(s) Name(s) or Placement Name			How long were you at this placement?
			(yy/mm)
What is the reason you left this placement?
If invited to live in a Jeremiah's Promise home, when would you be available to move in?			How long would you plan to stay?
			(yy/mm)
COUNTY CONTACT INFORMATION
Please provide names and contact information for all applicable contacts listed below. Please note that these references may be contacted in the process of determining your eligibility to move into a Jeremiah’s Promise home and may also be contacted periodically during and after your stay with us to ensure continuity of the services provided for your benefit.
Social Worker / After-Care Manager	Phone Number	Email
	(xxx-xxx-xxxx)
ILP Coordinator	Phone Number	Email
	(xxx-xxx-xxxx)
Case Manager	Phone Number	Email
	(xxx-xxx-xxxx)
Therapist	Phone Number	Email
	(xxx-xxx-xxxx)
Probation Officer	Phone Number	Email
	(xxx-xxx-xxxx)
CASA Advocate	Phone Number	Email
	(xxx-xxx-xxxx)
PERSONAL CONTACTS
Please provide contact information for 3 people whom you rely upon for natural support and/or people whom you would wish to be contacted in the case of an emergency (relatives, foster parents, pastors, mentors, friends, teachers, etc.).
Contact Name	Phone Number	Address
	(xxx-xxx-xxxx)
Contact Name	Phone Number	Address
	(xxx-xxx-xxxx)
Contact Name	Phone Number	Address
	(xxx-xxx-xxxx)
EDUCATION
Current Grade Level	Name of School Attending			When do you expect to graduate?
				(Month & Year)
School Address				School Phone Number

Have you completed or are you working to complete a GED?		If so, where?
Yes No
What are your plans after high school?

LEGAL HISTORY
Have you ever been arrested? If YES, please explain.
Yes No
Have you ever been arrested for/convicted of a violent crime against person or property? If YES, please explain.
Yes No
Have you ever been involved with a gang? Have you been active within a gang within the past year?
Yes No
MEDICAL HISTORY
Please provide the name of your physician and the medical facility where s/he practices.				Do you have a current MediCal Card?
				Yes No
Are you presently taking any medication and/or has any medication been prescribed for you within the past year? (Please list all medications prescribed for you by a doctor or psychiatrist within the past year and indicate which medications you are currently taking.)
Yes No
Have you intentionally hurt yourself in the past 5 years? If yes, please explain.
Yes No
Have you physically hurt someone else in the past 5 years? If yes, please explain.
Yes No
Have you ever been hospitalized for any reason? (medical or psychological) If yes, please explain.
Yes No
SUBSTANCE ABUSE HISTORY
Have you ever used drugs or alcohol or abused any other substances? If yes, what substance(s)?
Yes No
Have you ever been in a drug/alcohol dependency treatment program? If yes, for what substance(s)?
Yes No
HHave you participated in any 12-Step Programs? If yes, for what substance(s)?
Yes No
Do you currently use drugs/alcohol or other substances? If No, how long have you been clean and sober?
Yes No
INDEPENDENT LIVING SKILL INFORMATION
Have you participated in an ILP program?	Do you have experience cooking?	Do you have a bank account?
Yes No	Yes No	Yes No
How long have you had the bankaccount?	How much money have you saved?
	(yy/mm)
Do you currently have a job? If YES, where and for how long?
Yes No
Please list other jobs you have had in the past (if any).

Do you have experience using Public Transportation?			Yes No
Do you have a driver’s license?			Yes No
Do you own a car?			Yes No
Do you have a current insurance policy?			Yes No
BEFORE YOU SUBMIT...
I have voluntarily filled out this application and would like to be considered as a future Resident at a Jeremiah's Promise home. To the best of my knowledge, all of the above information is complete, true and correct. I understand that any or all of the county and/or personal contacts I have listed in this application may be contacted in the application process and/or during and after my stay at a Jeremiah’s Promise home to ensure the continuity of the services provided for my benefit.			Yes No

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TENANT APPLICATION

PLACEMENT INFORMATION

COUNTY CONTACT INFORMATION

PERSONAL CONTACTS

EDUCATION

LEGAL HISTORY

MEDICAL HISTORY

SUBSTANCE ABUSE HISTORY

INDEPENDENT LIVING SKILL INFORMATION

BEFORE YOU SUBMIT...