Application for Admission Application for Admission Admissions Application "*" indicates required fields Please read the statements and requirements below and check the box next to each to indicate your agreement.* I understand this application does not guarantee admittance into the Compassion Waco program. I must complete a face-to-face interview at the Compassion Waco Campus any Wednesday 9:30-11:30 AM in order for my application to be considered for the program. I understand that if I do not attend the interview, my application will not be complete and I will not be considered for the program. If I am accepted into the program at Compassion Waco, I agree to: Upon move-in* Pass an alcohol and drug screening. Pay one-time, non-refundable $100 utility fee. Pay one-time, refundable $100 security deposit. Provide social security cards, birth certificates, and insurance cards for all family members, if I have them. While participating in the program* Follow a daily cleaning checklist to make sure I keep my apartment orderly on a daily basis. Be in my apartment by curfew (10:00 p.m. Sun - Thurs and 11:00 p.m. Fri – Sat). Keep all guests out of my apartment. I know that guests can come in the lobby or outside from 5:30-8:00 p.m. Monday-Friday and noon-8:30 p.m. on Saturday and Sunday. Do my assigned chore every weekday to keep the areas inside and outside the building clean. Report all money that I receive while staying at Compassion including any government assistance and gifts. Attend a weekly budget meeting. Attend a weekly meeting with my case manager. Work on at least one life skill each week, to be determined by my case manager and myself. If unemployed at the time of intake, I understand I need to find full-time employment (35 hours or more each week) within 30 days of entering the program. Pay rent by the 1st of every month. Rent is based on income (minimum of $400/month) Attend monthly resident meetings. Name* SS#* Gender* Female Male Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ID or DL#* State* Expires* Email* Cell phone*Emergency ContactName* Telephone*Address* Relationship to you* Are you:Pregnant?* Yes No N/A A veteran?* Yes No Fleeing domestic violence?* Yes No Do you have a vehicle?* Yes No Make Model Color License Plate Ethnicity* Hispanic Non-Hispanic Race/Ethnicity* American Indian/Alaskan Native Asian Black/African American Hawaiian/Other Pacific Islander Hispanic White Multi Racial How did you learn about Compassion Waco? Friend/family Church 2-1-1 Online search Previous resident Other Other* EducationHighest Grade Completed (check one)* 6 7 8 9 10 11 12 other Other* Did you graduate from high school or receive a GED?* Yes No Name of high school* College or Technical School?* Yes No Where? When? Years attended Major HousingWhere did you sleep last night?* How long have you been staying there?* Have you been homeless before?* Yes No Have you stayed at Compassion Waco before?* Yes No If yes, when? Non-cash benefits/Income Sources: (Check all that apply you)* Earned Income TANF Child Support Veteran’s Benefits SSI/SSDI SNAP (food stamps) WIC (Women, Infants, Children) CCS (Child Care Services) Other (explain) None Monthly Amount* Monthly Amount* Monthly Amount* Monthly Amount* Monthly Amount* Monthly Amount* Monthly Amount* Monthly Amount* Other* Have you applied for SSI or SSDI?* Yes No Date of ApplicationMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employment HistoryAre you employed?* Yes No Current Employer Address Days/Hours Worked Full Time (35 hrs./wk. or more) Part Time Permanent Temporary Your current employer pays you: Weekly Bi Weekly Monthly Previous EmployersCompany Name Starting DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Company Name Starting DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenArrestedHave you been arrested before?* Yes No Where did offense occur?Where did offense occur?When?Nature of offense Add RemoveClick + for more than one arrestAre you on Probation or Parole?* Yes No If yes, name & phone of officer Do you have any open tickets or warrants?* Yes No Medical InformationHealth Insurance: (Check all that apply to you and your children)* None Private Insurance Good Health Card Adult Medicaid Children’s Medicaid CHIP Past and Current Medical HistoryAny medical or mental health diagnosis or accommodation?* Yes No If yes, describe List your current medications* Add RemoveHave you ever been a client at MHMR?* Yes No When? Have you been admitted to an inpatient/outpatient mental health facility?* Yes No Name of facility Date of admissionMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Substance Use/TreatmentWhen was the last time you used drugs or alcohol?* What was it? Have you ever been admitted to or completed a drug/alcohol treatment program?* Yes No When? Where? How long? Children that are moving in with youHave you ever had a CPS case?* Yes No When? Is the case currently open?* Yes No N/A Name of case worker Phone number of case worker How many Children?*123456Child 1Full Name* Gender* Female Male Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age* Social Security Number Any medical diagnosis or accommodation?* Yes No If yes, describe Medications School/Day Care name School/Day Care Phone Grade Last school attended Any special educational needs Race/Ethnicity* American Indian/Alaskan Native Asian Black/African American Hawaiian/Other Pacific Islander Hispanic White Multi Racial Child 2Full Name* Gender* Female Male Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age* Social Security Number Any medical diagnosis or accommodation?* Yes No If yes, describe Medications School/Day Care name School/Day Care Phone Grade Last school attended Any special educational needs Race/Ethnicity* American Indian/Alaskan Native Asian Black/African American Hawaiian/Other Pacific Islander Hispanic White Multi Racial Child 3Full Name* Gender* Female Male Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age* Social Security Number Any medical diagnosis or accommodation?* Yes No If yes, describe Medications School/Day Care name School/Day Care Phone Grade Last school attended Any special educational needs Race/Ethnicity* American Indian/Alaskan Native Asian Black/African American Hawaiian/Other Pacific Islander Hispanic White Multi Racial Child 4Full Name* Gender* Female Male Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age* Social Security Number Any medical diagnosis or accommodation?* Yes No If yes, describe Medications School/Day Care name School/Day Care Phone Grade Last school attended Any special educational needs Race/Ethnicity* American Indian/Alaskan Native Asian Black/African American Hawaiian/Other Pacific Islander Hispanic White Multi Racial Child 5Full Name* Gender* Female Male Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age* Social Security Number Any medical diagnosis or accommodation?* Yes No If yes, describe Medications School/Day Care name School/Day Care Phone Grade Last school attended Any special educational needs Race/Ethnicity* American Indian/Alaskan Native Asian Black/African American Hawaiian/Other Pacific Islander Hispanic White Multi Racial Child 6Full Name* Gender* Female Male Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age* Social Security Number Any medical diagnosis or accommodation?* Yes No If yes, describe Medications School/Day Care name School/Day Care Phone Grade Last school attended Any special educational needs Race/Ethnicity* American Indian/Alaskan Native Asian Black/African American Hawaiian/Other Pacific Islander Hispanic White Multi Racial HiddenConsentHiddenAgree I understand this application does not guarantee admittance into the Compassion Waco program. And I must undergo an interview at the Compassion Waco Campus on Wednesday between 2 - 4pm in order for my application to be considered for the program. I understand that if I do not attend the interview, my application will not be complete and I will not be considered for the program.