Transformational Housing Preliminary Application Step 1 of 2 50% Applicant InformationApplicant Name First Middle Last Date of Birth Date Format: MM slash DD slash YYYY Current AgeEmail Address Phone NumberWhen you submit your application, a case manager will call you at the number you provide within three business days. Is it OK to leave a message if we are directed to your voicemail?* Yes No What is the highest level of education you have completed?Some high schoolHigh school graduate or GEDSome collegeProfessional certificateAssociate's degreeBachelor's degree or aboveHow did you hear about the Front Door Agency?How many children do you have?1234+Information About Your ChildrenPlease list all children's names, ages and custody arrangements.Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Current Living SituationPlease describe your current living situation, including who you live with, any custody arrangements in place, etc. Save and Continue Later Program InformationTransformational Housing sites are located in Nashua, NH only. I have read the statement above. Are you ready and willing to work toward a higher education? Yes No Are you ready and willing to set goals and work hard towards reaching them? Yes No Are you ready and willing to prioritize healthy relationships and seek new supports? Yes No Are you ready and willing to actively seek and maintain appropriate, affordable and licensed child care for your children? Yes No Are you a victim or survivor of domestic violence?A crime in which there is a past or present familial, household, or other intimate relationship between the victim and the offender, including spouses, ex-spouses, boyfriends and girlfriends, ex-boyfriends or ex-girlfriends, parents and any family members or persons residing in the same household as the victim. Involves a pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner. Domestic violence can be physical, sexual, emotional, economic, or psychological actions or threats of actions that influence another person. This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone. Yes No In order to be successful in this program, each program participant must be able to maintain a 30- hour week that must include education and job skills training but can also include employment. At this point, what barriers are or have been preventing you from doing the above?Please check all that apply. Hold down "ctrl" and click to choose more than one option.Lack of educationNegative relationshipsDomestic violenceMental health concernsTransportation issuesSubstance misuse or abuseChildcare concernsInterpersonal problemsDisabilityLack of motivationCriminal recordLack of employment skillsNo routine (chaos)Financial barriersOther (please indicate below)Other:Anti-Discrimination Policy*The Front Door Agency, Inc. does not discriminate against any applicant on the basis of race, color, religion, national origin, age, sex or disability. The Front Door Agency will provide reasonable accommodations for persons with disabilities. Reasonable accommodations in rules, policies, practices and services will be allowed to give persons with disabilities an equal program, provided such accommodations do not impose an undue hardship to the agency. Applicants with disabilities seeking entry into our program and who can complete the program requirements with reasonable accommodations must notify the interviewer to make an accommodation request. I understand the above statement. Right to an Interpreter*The Front Door Agency, Inc. recognizes that clients and potential clients have a right to an interpreter. The agency will provide a phone interpreter at no cost to you through Language Line. If you require assistance filling out an application, please contact Emily Keane at (603) 816-0280. If you are determined to be eligible, the Front Door Agency will provide interpretation assistance via the Language Line to fill out an application and conduct an intake interview. I understand the above statement. Application Submission*By clicking "I agree" and then "Submit Application" I certify that all information provided on this form is true and correct to the best of my knowledge. I also hereby authorize a Front Door Agency Case Technician to contact past and present landlords, employers, and creditors for the purpose of verifying information for my application for assistance, as well as any City, State or Federal Agencies that are providing me or anyone in my household with assistance. I agree. CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.