Beacon Hill

A place for mothers with children

to find hope and a new beginning

ph: 907.222.0925
fax: 855.277.2004
info@beaconhillak.com

Housing Application

Apply for Housing

Please fill out all fields markedwith an *. You may also fax in a completed application by CLICKING HERE.

*Applicant's First Name:

*Applicant's Last Name:

*Applicant's Email:

*Best Phone Number to Reach Applicant:

*Is Applicant a US Citizen?:

*Applicant's Marital Status:

*Applicant's Date of Birth (mm/dd/yy):

Applicant's Ethnicity

Please List Any Disabilities of the Applicant:

*Name of Referring Agency / Church / Organization:

*Contact Person at Referring Agecny / Church / Organization:

*Contact Person's Email Address:

*Best Phone Number to Reach Agency Contact Person:

*Applicant's Start Date in Referring Agency's Program:

*Applicant's Length of Time in Agency's Program:

*Number of Children Living With Applicant:

*Ages of Children Living With Applicant:

*Does Applicant Have Minor Children Living Elsewhere (foster care, with relatives/friends, other)?:

Please List Any Disabilities of the Children:

Applicant's Last Permanent Address:

*When Did (or when will) Applicant Become Homeless:

*Has Applicant Been Previously Homeless:

If Yes, Please Provide All Dates of Previous Homelessness:

*Has Applicant Previously Stayed at a Shelter?:

If Yes, Please Indicate Dates and Program of Previous Shelter(s):

*Is Applicant Currently Employed?:

Applicant must be employed and working 20+ hours/week to qualify for housing at Beacon Hill.

*Please Briefly Explain the Applicant's Current Situation to Better Help the Management Make a Best Placement Decision for Housing:

*I, the referring party for the above named Applicant, understand that all information provided in this referral form is strictly confidential and will only be used to help the Board and Management Team of Beacon Hill make the best decision on the Guests of the home. I understand that these decisions depends on vacancy, best-fit in the home, and Board and Management discretion. I am aware of the criteria for all Guests of Beacon Hill and believe that the above named Applicant is a good candidate as a Guest in the home. I fully understand that applying as a Guest in Beacon Hill does not automatically qualify a Guest.

I agree and understand

*Name of Person Completing This Form:

Submit This Application for Housing: