LIFE Living Independent ForEver Program

www.shilohhousing.org 3127 Tarwater Avenue #4, Anchorage, Alaska 99508 – Phone: 907-770-2993 Fax: 907-770-0531

LIFE PROGRAM APPLICATION (18-24 YR OLD)

PERSONAL INFORMATION
*PLEASE BRING A GOVERNMENT ISSUED ID AND DOCUMENTED VERIFICATION OF SSN TO YOUR INITIAL APPOINTMENT
Office: 3127 Tarwater Streetof#4,
Name: ________________________*Date Anchorage,
Birth: Alaska
__________ 99508
*Social – Phone:
Security 907-770-2993
#: _________________
Current Address: ________________________________________State: _______ Zip: ___________
Previous Address: ____________________________________________________________________
Cell Phone: _____________________ Home Phone: _____________________
Email: ________________________________________________________________
If Homeless, how long: _______Where did you stay? _______________________________________
Referred by: _________________________________________________________________________
EMPLOYMENT INFORMATION
Place of Employment: _________________________________Phone Number: __________________
May we contact your employer? ______Yes ________No
Supervisor Name: ____________________________________Phone Number: __________________
Rate of Pay: ________Yrs. of Employment: ______________________
EDUCATION INFORMATION

Highest level of Education: _____High School ______College ____________Trade School

Enrolled in School? _____Yes ___________ No
If yes, where? ________________________________________________________________________
CRIMINAL HISTORY

Previous Criminal History? ______ Yes _____________ No

If yes, explain: ________________________________________________________________________

Are you currently on Probation or Parole? ______No ____Yes
Do you have an Open Criminal Case in Alaska or Any other State? ________Yes ________No
REFERENCES: (Please Supply Three Non-Relative References)

Name: __________________________________________________ Phone Number: _____________

Name: __________________________________________________ Phone Number: _____________

Name: __________________________________________________ Phone Number: _____________

EMERGENCY CONTACT

Nearest Relative: ____________________________________________Relationship: _____________

Address: ___________________________________________________Phone Number: _______________

Alternate Person: ____________________________________________Relationship: _____________

Address: ___________________________________________________Phone Number: _______________

Rev. 02/10/2020
Do you have any Medical or Physical Disabilities? ___No ____ Yes

Please explain: _______________________________________________

Please list any medications (prescribed and over the counter): _______________________________
____________________________________________________________________________________________________________________

Mental Health History, please list: ________________________________________________

Do you have any type of Allergies? _______________________________________________________

Did anyone assist in completing this application? __No __Yes (If yes, please list below)

Name: ________________________________________ Phone: __________________________

AUTHORIZATION FOR RELEASE OF INFORMATION
This form authorizes the core team/case manager to provide and/or obtain information from social
service agencies, relatives, church ministries, and other programs. The requested information will be used solely in the
administration of the LIFE Program and will be entered into the AKHMIS system for case management but will not be
released to any other persons or agency unless you authorize us to do so.

I (NAME OF APPLICANT) authorize the Shiloh

Community Housing, Inc.~ LIFE Program To obtain or provide information for the purpose of case management and referral
services as needed. This release of information is valid for a period of one year from the date signed. ·

SIGNATURE OF APPLICANT DATE

STATEMENT OF TRUTH
Under penalty of withdrawal from the LIFE Program, I certify that all information contained in this application is true and
correct to the best of my knowledge. I further understand that if at any time the information is found to be false or
omitted, I will automatically be withdrawing myself from the LIFE Program.
________________________________________________ ____________________
SIGNATURE OF APPLICANT DATE

ACCEPTED IN PROGRAM? ______Yes ________No

If Not Accepted, why not?

SIGNED DATE SIGNED DATE

Delmonicia D. Williams, Executive Director Shirley Midgett, Program Director

Shiloh Community Housing, Inc Fair Housing and Equal Opportunity Statement:
It is the policy of SCHI to provide equal employment and fair housing opportunity to all persons and to prohibit
discrimination because of race, color, religion, national origin, age, sex, and familial status. SCHI does not
discriminate on the basis of a disability status in admission or access to its transitional housing programs and
activities.

A Shiloh Community Housing, Inc. Program

Rev. 02/10/2020