Lighthouse Beloved Community Application Form

Lighthouse Beloved Community Questionnaire

This questionnaire will be used to gather general information for statistical purposes and help us provide you with more information on the Lighthouse Beloved Community. We respect your privacy.
Head of Household Information
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Date Of Birth*

MonthDayYear
Date
E-mail
Additional Adult Applicant
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Date
General Household Information
How many adults are currently living in your household?*
How many children (18 and younger) are currently living in your household?*
Are you a recipient of a housing choice voucher*
Have you or additional applicant(s) ever been arrested for a misdemeanor or felony*
Are you or additional applicant(s) required to register as a lifetime sex offender in any state*
Race is requested for reporting to the U.S. Department of Housing and Urban development (HUD) and is used for statistical purposes only to ensure non-discrimination*
Ethnicity is requested for reporting to the U.S. Department of Housing and Urban development (HUD) and is used for statistical purposes only to ensure non-discrimination*
Alternative Contact Information

If you are filling out this form for someone else and would like to be the primary contact, please fill out your information below.
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
What is your relationship to the applicant?

FamilyFriendSocial WorkerPeer SupportOther
Contact Preferences

Let us know how you would like to receive more information on the Lighthouse Beloved Community!
How would you prefer to receive information on the Lighthouse Beloved Community?*

EmailMailing AddressP.O. Box
Email: If you chose 'Email' as your preferred method of contact, please provide your preferred email.
example@example.com
Address: If you chose 'Mailing Address' or 'P.O. Box' as your preferred method of contact, please provide your preferred address.

Street Address

Street Address (Apt. #, P.O. Box, etc.)

CityState / Province

Postal / Zip Code
Additional Comments:
Should be Empty:

Lighthouse Beloved Community Questionnaire

Head of Household Information

Additional Adult Applicant

General Household Information

Alternative Contact Information

Contact Preferences