Resident Application Form

PERSONAL INFORMATION

Full Name

Date of Birth:

Social Security Number:

Gender:

Email Address

Phone Number:

Current Address:

City:

State:

Zip Code:

EMERGENCY CONTACT INFORMATION

Primary Contact Name:

Relationship

Phone Number:

Alternate Phone Number:

Email Address

MEDICAL INFORMATION

Primary Physician Name:

Phone Number:

Known Allergies:

Current Medications:

Medical Conditions:

Insurance Provider:

Policy Number:

LIVING ARRANGEMENT

Preferred Location:

Date Available to Move In:

Room Type Preference:

Do you require any special accommodations?

If yes, please describe:

BACKGROUND INFORMATION

Have you ever been convicted of a felony?

If yes, please explain:

Do you have any pending criminal charges?

If yes, please explain:

Are you currently under probation or parole?

PERSONAL HISTORY

Current Living Situation:

Reason for Applying to Gifted Lives:

PREVIOUS RESIDENCES (PAST 3 YEARS):

Address 1:

Date:

Address 2:

Date:

AGREEMENT AND SIGNATURE

I hereby certify that the information provided is true and complete to the best of my knowledge. I understand that false information may result in the denial or termination of my residency.