Application for Residency

Personal Information

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Other names you've gone by:

List 3 previous addresses & how long you lived there:

Emergency Contact

First Name

Last Name

Emergency Contact Relationship:

Emergency Contact Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employment Information

Current employer:

Position:

How long?

Employer Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone:

Annual income:

Wage

Select one:

THREE REFERENCES (NO RELATIVES):

Reference 1:

Name & Relationship: Address: City: State:

Reference 2:

Name & Relationship: Address: City: State:

Reference 3:

Name & Relationship: Address: City: State:

Education:

1. Name of school & City/State: Grade & Last Year Attended: Special Skills: 2. Name of school & City/State: Grade & Last Year Attended: Special Skills:

HEALTH

Do you smoke?

History of Drug or Alcohol Abuse?

If yes, Explain:

Personal or Family History of Mental Illness?

Any other health issues that require special care?

CHILDREN

If pregnant list due date, sex & name of child if known:

Name & Birthdate:

POLICE RECORD, ARRESTS, LEGAL CHARGES

Please list and explain ALL police records, arrests, charges, current warrants, and city/state and date occurred(even if dismissed):

APPLICATION ESSAY

1. Please tell us why you think Madonna House is the right place for you to live:

2. Why do you feel you are a good candidate for residency? What concerns do you have with the program?

What do you expect to accomplish during your residency in our program? How do you believe Madonna House can help you obtain these goals?

Authorization for Background Check

I authorize Madonna House of Northern Kentucky to investigate my background and qualifications for the purposes of evaluating whether I am qualified for the position for which I am applying. I understand that Madonna House will utilize an outside firm or firms to assist in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for the position will not be processed further.

Yes

Applicant Name & Current Address or last permanent address

Previous Address

Driver's License Number

Date of Birth

YYYY

Authorization to Disclose or Obtain Information

I authorize Madonna House of NKY to obtain/release information concerning me and/or my children to/from the members of the Pregnancy Care Network for the purposes of case conferencing in order to coordinate services. I acknowledge that the disclosure or use of the above information is confidential and is intended to be shared only with those parties named. I recognize that this information may be subject to inadvertent or uncontrollable reuse or disclosure through no intent or fault of the parties named. I understand that I have a right to refuse to sign this document and that such refusal will not cause me to be denied services. I understand that I may revoke this authorization any time prior to the dates indicated above by notifying my service provider. I understand that I have a right to inspect a copy of the written information to be used or disclosed.

Authorization to Allow Madonna House Staff to Obtain Information from Social Networks

I authorize Madonna House Staff to access my social networks, including Facebook, during the interview, in order to further determine my eligibility for the program. I will cooperate with this process by providing my identity (staff will not require passwords) on the networks and making it public for the interviewers or by accessing the network myself while they are present.