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Acceptance Criteria

Women over the age of 18.
If you have children, they need to be under the age of 10 due to the space in the rooms provided.
No open/active arrest warrants.
At least a year clean from drugs and or alcohol.
Individuals with a history of violence, theft, or needing psychotropic medications will be carefully considered.
Must be willing to work while in the program.
Those outside of Lancaster County will be considered on a case by case basis.

Home on Ferdinand Application

Personal Information

First name*

Last name*

Age*

Date of Birth*

Phone Number*

Email*

Ethnicity*

White/Caucasian

Black/African American

Asian

Indigenous/Native American

Hawaiian/Pacific Islander

Hispanic or Latino

Prefer not to say

What was your last permanent address?*

Do you have a personal vehicle?*

Yes

No

If working with a housing provider, please provide their contact information.

Name of Provider/Organization

Name of Case Manager

Phone Number

Children

Please fill out the following for each child that will be living with you. ** If you do not have children, please leave blank.

Full Name (First and Last)

Date of Birth

Gender

Full Name (First and Last)

Date of Birth

Gender

Full Name (First and Last)

Date of Birth

Gender

Full Name (First and Last)

Date of Birth

Gender

Do you have childcare?

Yes

No

Are you enrolled with Child Works/ELRC (Early Learning Resource Center)?

Yes

No

Where do your children go to school?

Housing History

Have you ever been a participant in our program before?*

Yes

No

If yes, when?

Did you speak with 211?*

Yes

No

Have you ever experienced homelessness before?*

Yes

No

If yes, where did you stay and for how long were you homeless?

If yes, when did you experience each episode of homelessness?

Do you have any evictions?*

Yes

No

If yes, how many, if none please select none.*

None

1

2

3 or more

Health and Well Being

Are you pregnant or think you may be?*

Yes

No

If yes, what is your estimated due date?

Are you currently using or have used in the last 12 months any illegal substances or are you struggling with alcohol?*

Yes

No

If yes, please specify.

Were you recently in a hospital or rehab?*

Yes

No

If yes, where?

Will you need ongoing care?

Yes

No

Do you require any ADA accommodations?*

Yes

No

If yes, please specify.

Do you have any past substance or alcohol abuse?*

Yes

No

If yes, how long have you been sober?

Do you have any mental health diagnoses?*

Yes

No

If yes, please specify.

If yes, are you on any medication currently?

Are you currently fleeing domestic abuse?*

Yes

No

Do you have a PFA against someone?*

Yes

No

Is there a PFA against you?*

Yes

No

Financial and Legal History

Are you currently employed?*

Yes

No

If yes, where do you work and is it full-time or part-time?

If you are not employed, what are your employment plans?

Please list what you receive MONTHLY for each category below.

Employment

Cash Assistance

SNAP

Child Support

Social Security Income (SSI)

Social Security Disability Income (SSDI)

Do you have any debt?*

Yes

No

If yes, please specify an amount.

Are you on Megan's law?*

Yes

No

Do you have a criminal background (charges or convictions)?*

Yes

No

If yes, what were they?

How long ago were these charges?

Do you currently have any arrest warrants?*

Yes

No

Were you recently incarcerated?*

Yes

No

Are you on probation or parole?*

Yes

No

Are you a resident of Lancaster County?*

Yes

No

Can you tell me a little more about your situation? (How did you lose your previous housing? Where are you staying now?)

Copyright © 2023 Manheim Community Life Group, All rights reserved.
Manheim community life group is a 501(c)(3) nonprofit organization- contributions to which are tax-deductible to the fullest extent permitted by law.

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