LinkedInThis field is for validation purposes and should be left unchanged.Visitation House Resident Application Application Submission Form. Please fill out all fields. Place N/A in fields you do not have information for.Applicant InformationName First Last Age(Required)Where are you currently living? My Home Other's Home Shelter Hotel Unhoused It Varies Other Phone(Required)Email Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital StatusSingleMarriedDivorcedSeparatedAlternate Phone 1What is the best way to reach you? Phone Text message Email If no answer Is it ok to leave a message? Do not leave a message Drivers License NumberDrivers License Expiration DateDo you drive? Yes No Do you have a car? Yes No Birth Father InformationName First Last Are you still in a relationship with him? Yes No Is he in the local area? Yes No Is he aware of the pregnancy? Yes No Please check all that apply about the father: Supportive Abusive Neglectful Attentive Employed Unemployed Responsible Irresponsible Violent Drug / Alcohol Dependent Married to someone else DependentsDo you have other children? Yes No Number of childrenPlease enter a number from 0 to 6.Use a separate sheet to list over six children. Use a separate sheet to list over six children. Child's NameChild's AgeExplain any special needsAre they living with you/in your custody? Yes No Who currently has custody? Please explain.Child's NameChild's AgeExplain any special needsAre they living with you/in your custody? Yes No Who currently has custody? Please explain.Child's NameChild's AgeExplain any special needsAre they living with you/in your custody? Yes No Who currently has custody? Please explain.Child's NameChild's AgeExplain any special needsAre they living with you/in your custody? Yes No Who currently has custody? Please explain.Child's NameChild's AgeExplain any special needsAre they living with you/in your custody? Yes No Who currently has custody? Please explain.Child's NameChild's AgeExplain any special needsAre they living with you/in your custody? Yes No Who currently has custody? Please explain.EducationName of last school attended?Are you planning to further your education? Yes No FinancialAre you currently working? Yes No Where was your last job?Where was your best job?Do you currently receive? SSI WIC Medicaid Foodstamps Do you have any other sources of income?? Yes No List all other sources of income.Health InformationHave you been diagnosed with any medical condition Yes No Please list and explain your medical condition(s)What is your baby's due date? MM slash DD slash YYYY If unknown, approximately how many weeks pregnant are you?Have you currently secured an OB/Gyn physician? Yes No Doctor's nameCheck other medical services you recerive. Primary Care Specialists Psychiatric / Counseling If you have you ever been hospitalized for a physical or mental condition, list when and where.If you are you taking any prescription medications. please list them.If you currently drink alcohol, or use recreational drugs, how much and how often?Legal InformationHave you ever been arrested? If yes please explain.Do you have any pending court dates? If so please list.Are you on probation or parole? If so please explain.OtherWhat is your current relationship with your family?Do you have a religious preference? If yes, what denomination?What would you like to see happen in your life while at the Visitation House?How did you hear about us?Please indicate any other information that you would like us to know.I have read the Rules of the Visitation House and promise to abide by them.(Required) Yes No
