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GENERAL INFORMATION:
Select a Location:
Clay County    Eastern Jackson County   Platte County   Wyandotte County

Applicant First Name: Applicant Last Name:
Co-Applicant First Name: Co-Applicant Last Name:
Phone Number:

Where are you living right now? (select one):
Address: Phone:
How long have you been staying there?

Ever applied/lived at Hillcrest before? Yes   No

Referred to Hillcrest Ministries by:



List all who would be living in the apartment (including yourself):
Name Relationship Date of Birth Soc. Sec. # Grade/School Father's Name Type of Custody
Anyone pregnant?  YesNo Due Date:  


Bills and Debts: (complete the attached list and add any items not listed)
Item Amt Due Mo Payment Past Due?   Item Amt Due Mo Payment Past Due?
Past Rent YesNo   Pawn Shop YesNo
Cable YesNo   Payday Loans YesNo
Electric YesNo   Tickets/Fines YesNo
Gas YesNo   Bankruptcy YesNo
Telephone YesNo   Credit Cards YesNo
Water YesNo   Storage YesNo
Student Loan YesNo   Childcare YesNo
Medical YesNo   Auto Payment YesNo
Clubs YesNo   Auto Insurance YesNo
Child Support YesNo   Title Loans YesNo
Repossessions YesNo   Cell/Pager YesNo
Bad Checks YesNo   Other YesNo
Other YesNo   Other YesNo
Other YesNo   Other YesNo


Income currently received from job, child support, DFS, SSI, etc.:
If child support is owed to you, please list monthly/total amount owed.
Source Monthly Amount

Current Case Worker Name?     Phone #:  

Name of Social Services Office:  


Please explain briefly the reasons for your current situation:


Do you or any family members receive any medical or counseling services?
Name Problem Medication


Drivers License Number:     State:    Expiration: 
Do you have a car? YesNo
   Year:     Model:     Insurance? YesNo
   Tag Number:     Current? YesNo    State:     Current Inspection? YesNo


References/Emergency Contact:
Name Address Phone Relationship



APPLICANT PERSONAL HISTORY:
Age:    Social Security Number:    Date of Birth:
Location of Birth:
Married   Single   Divorced   Separated   Widowed     Previous marriages? Yes No


Education
Level: (select one)     School Grade Average (select one)

Name of School Year Graduated
High School/GED
Junior College
4 Year College


Job History Information (Last 5 Years):
Year Company Name Pay Rate Duties Reason for Leaving


Family
Parents Names Address (city, state) Phone


Brothers/Sisters Names Address (city, state) Phone


Do you smoke? Yes No    How much per day?

Do you use drugs or alcohol? Yes No

Ever been in drug or alcohol rehabilitation? Yes No
    If yes, when:    Name of abused substance:
    Facility:    AA Participant? YesNo    NA Participant? YesNo

Have you ever been arrested? (DWI, bad checks, assault, etc.) YesNo
    What for?    Did you receive a fine/sentence? YesNo

Have you been a battered person? YesNo   When?

Have you served any time in jail?   YesNo   How Long?

Do you have any pending tickets? (speeding, parking, etc.) YesNo
    What for?   When is your court date?

Are you on parole or probation at present? Yes No   How long?
    Parole/Probation officer:    Phone Number:

Is there a warrant/s out for your arrest at present? Yes No
    Reason:



CO-APPLICANT PERSONAL HISTORY:
Age:    Social Security Number:    Date of Birth:
Location of Birth:
Married   Single   Divorced   Separated   Widowed     Previous marriages? Yes No


Education
Level: (select one)     School Grade Average (select one)

Name of School Year Graduated
High School/GED
Junior College
4 Year College


Job History Information (Last 5 Years):
Year Company Name Pay Rate Duties Reason for Leaving


Family
Parents Names Address (city, state) Phone


Brothers/Sisters Names Address (city, state) Phone


Do you smoke? Yes No    How much per day?

Do you use drugs or alcohol? Yes No

Ever been in drug or alcohol rehabilitation? Yes No
    If yes, when:    Name of abused substance:
    Facility:    AA Participant? YesNo    NA Participant? YesNo

Have you ever been arrested? (DWI, bad checks, assault, etc.) YesNo
    What for?    Did you receive a fine/sentence? YesNo

Have you been a battered person? YesNo   When?

Have you served any time in jail?   YesNo   How Long?

Do you have any pending tickets? (speeding, parking, etc.) YesNo
    What for?   When is your court date?

Are you on parole or probation at present? Yes No   How long?
    Parole/Probation officer:    Phone Number:

Is there a warrant/s out for your arrest at present? Yes No
    Reason:




Rules of Residence

The following rules of conduct shall be in effect while a guest family resides in any Hillcrest apartment. Violation of any rule will, at the sole discretion of the Board or Staff, be cause for immediate dismissal from the building and program.

  1. No illegal activity of any kind will be permitted
  2. Use or possession of alcohol or illegal drugs is prohibited.
  3. Curfew is 11:00 pm. This can only be waived for work schedules. Guests must be out of the houses by 10:00 pm. Quiet hours are: 10:00 pm through 7:00 am.
  4. No overnight guests are allowed unless permission is obtained through a staff member.
  5. Children under the age of 13 must be attended by an approved adult at all times.
  6. Children must be enrolled in the Liberty School District. They must attend school everyday required in the Hillcrest Zone.
  7. No fighting of any kind will be tolerated.
  8. No pets of any kind will be allowed.
  9. Smoking is Not permitted inside the apartments, houses, or offices.
  10. Guest families must keep apartments clean and neat.
  11. All adults living at Hillcrest are expected to work at least 40 hours per week.
  12. All adults must attend scheduled meetings & appointments.
  13. A $100 deposit will be taken at time of move in, or at time of first paycheck, to cover costs of cleaning, damage, or non-completion of program.
I have read and understand that if I violate any one of these rules I may be dismissed from the Hillcrest program. I agree to hold Hillcrest Ministries and/or any other parties associated with this program in any way whatsoever, singly, or collectively, from any blame or liability for injury, misadventure, harm, loss, inconvenience, or damage suffered or sustained as a result of participation in this program or in activities associated therewith. I give permission for information to be released about me and my children, by or to any doctor, social worker, counselor, employer, landlord, shelter, agency, including Mid America Assistance Coalition database, or any other person deemed necessary by Hillcrest Ministries.

By submitting this application, I agree that the preceding information is true and accurate to the best of my knowledge, and I understand and agree to the Rules as put forth above.

Signature: