ONLINE APPLICATION

Please fill out the information below and we will be in touch!

Your Name (required)

Your Email (required)

Phone (required)

Address (required)

City (required)

State(required)

Birth Date (required)

Marital StatusSingleMarried/RemarriedSeparatedDivorcedWidowed

Age(required)

GenderMaleFemale

Place of Birth

HOUSING: Current living arrangements AloneWith Others

What are your current monthly housing expenses?

Residence History:

Have you ever owned your own home? YesNo

If yes, what year did you sell?

Date you wish to move in:

Frequently our vacancies are unexpected. Can you be ready to move on a month’s notice or less?YesNo

The current monthly cost is $1,500.00 which includes private bedroom, meals, housekeeping, and utilities. Will you need a rent subsidy?YesNo

If yes, have you already applied for this?YesNo

Name of organization(s) to which you have applied:

MEDICAL QUESTIONS:
We do not discriminate or withhold residency from anyone with a history of any medical, psychiatric, or substance abuse problem.

A doctor’s report will be requested. Please provide the following information:

Primary physician’s name:

Address:

Phone:

We do require full disclosure of past medical history – Please tell us about your medical history and medications:

Please be aware that a resident who becomes unable or unwilling to self-medicate will no longer be considered eligible for residency.

What kinds of hospitalizations have you had during your lifetime:

Have you been admitted to a hospital within the last year?YesNo

If yes, for what reason and what hospital:

Have you ever been admitted to a rehabilitation facility? YesNo

Are you currently or have you ever been under the care of a psychologist/psychiatrist/
therapist? YesNo

Do you have a history of alcohol or drug/substance abuse? YesNo
Please describe
Are you currently a smoker?YesNo

Smoking is not allowed in either residence nor anywhere on the premises.

FAMILY INFORMATION: We require each resident to have a “Contact Person” in the vicinity of Ridgewood on whom we may call in case of emergency. Name of person who would act in that capacity for you:

Name:
Relationship to you:
Address:
Phone:
E-mail:

SUPPORTS:

Has anyone been appointed Power of Attorney or guardian? YesNo

If yes, please name:

Relationship to you:

Address:

Phone:

To what extent? Legal/financialMedicalBothOther

Has an Advanced Directive and/or Living Will been prepared? YesNo

Person financially responsible to SHARE, INC., if other than yourself.

Name:
Relationship to you:
Address:
Cell phone:
Home phone:
Business phone:

PERSONAL

Why have you chosen to seek residency at a shared house?

How did you hear about our houses?

Do you have any special hobbies, interests or vocation? Please describe:

Our residents have meals together and occasionally participate in some group activities.
Much time is spent alone, however, doing what each person enjoys. At present, how do
you usually spend your day?

Are you bringing a car? YesNo

Parking is subject to availability and subject to the discretion of the Board of Directors.

SHARE RESPONSIBILITIES
Weekly housekeeping is professionally done. However, our residents do have a SHARING SCHEDULE at meal time: In teams of two, one day a week, they set/clear the dining tables, load the dishwasher, and wipe off the tables.

How do you feel about such participation?

Two people share a bathroom at all times, during your residency with us you may be
required to share a bathroom with a person of the opposite sex, how do you feel about
this?

Meetings with residents are held once a month to exchange ideas and suggestions.
How do you feel about such participation?

Is there anything we have not covered that you would like us to know about you or your
housing requirements? Please specify:

Please leave this field empty.

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