Application Form

REQUEST FOR ADMISSION APPLICATION

Personal Information

Full Legal Name *

Date of Birth

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Social Security Number *

Email Address *

Phone Number *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Current Employer (Most Recent if Currently Unemployed): *

Are you of Hispanic, Latino, or of Spanish origin? (Your Ethnicity): *YesNo

How would you describe your Ancestral Lineage (Your Race): *African American (Black)American Indian or Alaska NativeAsianCaucasian (White)Native Hawaiian or Pacific IslanderOther (May be Asked for Clarification)

Are You A Veteran? *YesNo

My biological sex assigned to me at birth was: *MaleFemaleNon-BinaryNot Specified/Designated on Birth Certificate

Gender

The Following Questions Addressing Applicant Gender Are Offered In Order To Provide Mandatory Personalized Healthcare and Appropriate On-Site Housing Arrangements *

* The information gathered from the following questions is intended to assist in equipping our staff with the current most accurate information concerning all potential residents. This information is relevant in determining open bed availability and in assessing the healthcare requirements for both present and future residents on a case-by-case basis.

 

At Carter Hope we recognize that identities and terminologies used by the LGBTQIA+ community are ever evolving. We have elected to offer acceptable alternative answers to the following gender specific questions and are aware that the options provided are by no means exhaustive. We support and encourage each applicant to offer appropriate clarification to any and all details provided with this form as the individual deems necessary. Additional information provided may be used in conjunction with the information on this form in our consideration for resident admittance. 

 

All personal information submitted by every applicant is regarded as confidential indeterminate of program acceptance. Carter Hope Staff Members and Affiliated Personnel will always make reasonable efforts to prevent the inadvertent or unauthorized disclosure of, or unauthorized access to, any information relating to an individual sharing with us, UNLESS:

• the individual(s) may be an immediate danger to themselves or another
• the individual(s) is/are endangering another who cannot protect themselves, as in the case of a child, a person with a disability, or elder abuse
• when required to obtain payment for services
• as required by mandate of state or federal laws

** Clarification May Be Requested Before Admission is Approved. **

Have you transitioned, or are you in the process of transitioning your gender status? *YesNo

If you answered Yes to the question above, what is your current transitional status:

I identify to the following pronouns: *He / Him / HisShe / Her / HersThey / Them / TheirsZe / ZirOther

My current sexual orientation is: *StraightLesbianGayBisexualPansexualQueerAsexualQuestioningDecline to Answer