Homes for Hearts (HFH) Resident Agreement, Application & Intake Questionnaire
Date: ______________
Applicant Name: ___________________________________________________ (Please Print clearly)
========================================================================
Below For Vetting Committee Use Only ========================================================================
Date
Application Received By Vetting ___________________
Background Check Done ___________________
Background Check Outcome ___________________
Vetting Review Done ___________________
Reviewers response
Initial: _____ Candidate(Y/N): ___
Initial: _____ Candidate(Y/N): ___
Initial: _____ Candidate(Y/N): ___
Initial: _____ Candidate(Y/N): ___
Initial: _____ Candidate(Y/N): ___
1st Contact for Interview ________________________________
2nd Contact for Interview ________________________________
3rd Contact for Interview ________________________________
Interview Date _________________
Resolution and Date _________________ _________________
Homes for Hearts (HFH) Community Agreement
HFH is an affordable, permanent homestead that provides a safe and secure place to be for those currently without housing. It is a self-governing community that is based on five basic rules:
- No violence to yourselves or others
- No theft
- No alcohol, illegal drugs, or drug paraphernalia
- No persistent, disruptive behavior
- Everyone must contribute to the operation and maintenance of the Homestead.
I will be a positive member of this community and contribute toward making it a safe, secure, clean and pleasant place to live.
Therefore I agree to the following:
- What I do will be based on love and respect for myself and others.
- I will not disrespect others based on ethnicity, religion, gender, sexual orientation, handicap, lifestyle choices, or economic status. We all have the right to expect dignity and opportunity.
- I will help make HFH a place where everyone feels safe and respected. For my own safety as well as the safety of others, I will not carry a weapon or act violently toward others or myself.
- Since stealing is one of the most upsetting things that can happen in our community, I will not steal and will make the members of the Homestead Council aware of any stealing I see. I will respect other people’s property and community property and I expect other people to respect mine.
- I know that illegal drugs and alcohol use can damage my community. I agree not to use illegal drugs or alcohol while at the Homestead.
- I will honor quiet hours from 10PM to 7AM so that others and myself can stay healthy and rested. I understand that no personal guests will be allowed during that time.
- I want to live in a clean, litter-free, comfortable space where I can bring friends, family and other guests. Also, I know that many communities such as ours get closed down for “health and safety” reasons. I will keep the area in and around where I live clean and orderly, and not store any personal items outside of my building footprint or allocated storage space. I will help keep the community areas clean and will pick up after myself and my pet, if I have one, and keep my pet leashed at all times. I understand that only a limited number of pets will be allowed in the Homestead in order to maintain an orderly environment.
- I understand that in order to maintain a secure environment there will be a single point of entrance and exit that will be staffed 24/7, and that security shifts will be shared equally among Homestead residents.
- I know that it can take a lot of work to keep the Homestead a safe, clean and pleasant place to live. I agree to work at least 10 hours a week on the operation and maintenance of the Homestead. This includes serving on security teams, helping with kitchen duties, construction projects, maintenance and clean-up crews, helping plan activities and other jobs that need to be shared by community members.
- I also know that there are financial costs to keep the Homestead running. I will support the goal of self-sufficiency by contributing each month either financially or through sweat equity by participating in micro-business opportunities or fundraising events.
- I will attend the weekly Homestead meetings, unless I have an acceptable reason for absence, in which case I will find out what went on by reading the meeting notes. I understand that decisions will be made through a majority vote, and that the Board of Directors of the non-profit reserves the right to override decisions made. I agree to abide by all decisions made.
- I affirm that I have completed the Background Check Form honestly along with all other application documents. I understand that if the background check reveals otherwise, I could be asked to leave immediately.
I promise to keep all of these agreements, as well as others that are approved at Homestead meetings. If I violate any agreements, the members of the Homestead Council are authorized to ask me to leave temporarily, or, in serious or repeat cases, to leave permanently. I will do so peacefully and not return unless I am authorized to do so.
I know that HFH is a place where people value community and support each other. I will try to think of ways to make our community a better place to be. When I am concerned or upset with situations in the Homestead, I will bring these problems to the attention of the appropriate people so that we can work together to figure things out. I willingly sign these agreements that are a contract between Homes for Hearts and me.
Name (Signature): _____________________________________________________
Date: __________________________
Homes for Hearts (HFH) Application & Intake Questionnaire
Date: __________________ Legal/Given Name: __________________________________________________________________
Name Used: ________________________________________________________________________
Race/Ethnicity: ______________________ Gender: ___________________
Driver’s License/State ID number: ________________________ State issued: __________
How do we contact you?
Location: ________________________________________________
Phone: __________________________________________________
Email: ___________________________________________________
Where did you sleep last night: ____________________________________________________________________________
Date of birth: _____________________ Circle one: Single / Married / Partnered
Is your spouse/partner applying to HFH? Yes / No
If so, spouse/partner’s name:_____________________________________________________
Do you have children with you? Yes / No If so, how old are they? ___________________
Do you have a car? Yes / No Do you have an RV? Yes / No
How much stuff do you have? Backpack / Car load / Truck load / Storage Unit
Do you have a pet? Yes/No
If so, what kind? _____________ How many pounds? _____________ Spay/neuter? Yes/No
- How did you become unhoused? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- How long have you been without stable housing? _________________________________________
- Where was your most recent permanent address? _________________________________________
- How long have you been in the Memphis/Tennessee Area? __________________________________
- Is this your first experience being unhoused? ____________________________________________
- Do you have a source of income? Yes / No If so, what source? ___________________________
- Do you get food stamps? Yes / No If not, do you want help applying? Yes / No
- Are you on OHP? Yes / No If not, do you want help applying? Yes / No
- Do you receive SSI/SSDI? Yes / No If not, do you want help applying? Yes / No
- Are you on any housing lists? Yes / No If so, which? ______________________________
________________________________________ If not, do you want help applying? Yes / No
- Have you been active in houseless issues/activism? Yes / No If so, how? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Have you ever lived in a rest stop, homeless village or other community environment? Yes / No
If so, which one and for how long? ________________________________________________
- Are you a veteran? Yes / No Branch: _______________ Type of discharge: __________
- Are you employed? Yes / No If so, where and how many hours/week? ________________________________________________________________________________________________________________________________________________________
- Do you have a disability or special needs? Yes / No If so, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Female head of household? Yes/No
- Elderly head of household (over 65)? Yes/ No
- What goals do you have for yourself? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Is there anything you would like to tell us about yourself? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Skills Inventory
- How far have you gone in school? _____________________________________________________
- What did you study? _______________________________________________________________
- Any plans to go back to school? Yes / No To study what? ________________________________
- Have you worked for pay? Yes / No If so, what kinds of work have you done?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- What is the best job you ever had? ____________________________________________________
Why? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- What are your hobbies? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
7.What of the following do you have experience with? (Check all that apply)
Rough Carpentry____
Finish Carpentry ____
Plumbing ____
Electrical ____
Gardening ____
Farming ____
Security (Military/Law enforcement/Private) ____
Permaculture ____
HVAC ____
Inventing ____
Masonry ____
Driver ____
Mechanic/small engine repair ____
Chimney Sweeping ____
Roofing ____
Cooking/Food Service ____
Computers, Web Development ____
Computers, Word ____
Processing/Spreadsheets ____
Computers, Data Entry ____
Computers, Desktop publishing ____
Writing ____
Business owner ____
Activism/Community Organizing ____
Management ____
Community/Political Leader ____
Masonry ____
Spiritual Leadership ____
Sales ____
First Aid ____
Bookkeeping/managing money ____
Computers, Programing ____
Office Manager ____
Other: ________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
8.Things you are interested in contribution to Homestead life:
Creative/Artistic ____
Communications/Outreach ____
Drawing, Illustration ____
Speaking/Presenting to groups ____
Writing – Promos, ads… ____
Filing ____
Stuffing Envelopes ____
Sewing/knitting ____
Coordination Volunteers ____
Bookkeeping/Accounting ____
Computer repair ____
Legal/Paralegal ____
Specific Software ____
Electrical ____
Medical/first aid (list certification) ____ / _________________________
Sign making/painting ____
Desktop publishing ____
Computer Graphics ____
Office and Administrative ____
Performance – acting, music, dance… ____
Cooking ____
Phone Calls ____
Computers ____
Networking ____
Note take, keeping minutes ____
Data Entry ____
Technical ____
Driving (list license type) ____ / ____________________
Carpentry ____
Plumbing ____
Roofing
Drafting/reading technical plans
Masonry
Leading work parties
Painting
Glazing
Landscaping
Gardening
Labor
Other: ________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Please provide an Emergency Contact:
____________________________________ _______________ _______________ Name Phone Relationship
Homes for Hearts (HFH) Background Check Form
Notice: We will conduct a background check on all applicants. If that background check does not match your answers on this form, your application to live in Homes for Hearts will be denied. The only criminal offenses that automatically exclude are forcible/aggravated rape and sexual predation on children. PLEASE BE HONEST!
Last Name: ______________________ First Name: ______________________
Middle Name: ______________________
Date of Birth: ______________Last 4 digits of SSN:______________
Have you ever been convicted of a criminal offense? Yes / No
If yes, please state the City/Town, County and State, the date of the conviction, and charges you were convicted of. (Please use the back of the sheet if you need more room).
- __________________________________ / _______________
City, State, County Date/Yr
____________________________________________________________________________
Offense
- __________________________________ / _______________
City, State, County Date/Yr
____________________________________________________________________________
Offense
- __________________________________ / _______________
City, State, County Date/Yr
____________________________________________________________________________
Offense
The information on this form is true and accurate to the best of my knowledge. I give permission to verify all information provided.
__________________________________________________ / ________________________ Applicant Signature Date
__________________________________________________ / ________________________
HFH Representative Date
Homes for Hearts (HFH) Resident Agreement, Application & Intake Questionnaire
Date: ______________
Applicant Name: ___________________________________________________ (Please Print clearly)
========================================================================
Below For Vetting Committee Use Only ========================================================================
Date
Application Received By Vetting ___________________
Background Check Done ___________________
Background Check Outcome ___________________
Vetting Review Done ___________________
Reviewers response
Initial: _____ Candidate(Y/N): ___
Initial: _____ Candidate(Y/N): ___
Initial: _____ Candidate(Y/N): ___
Initial: _____ Candidate(Y/N): ___
Initial: _____ Candidate(Y/N): ___
1st Contact for Interview ________________________________
2nd Contact for Interview ________________________________
3rd Contact for Interview ________________________________
Interview Date _________________
Resolution and Date _________________ _________________
Homes for Hearts (HFH) Community Agreement
HFH is an affordable, permanent homestead that provides a safe and secure place to be for those currently without housing. It is a self-governing community that is based on five basic rules:
- No violence to yourselves or others
- No theft
- No alcohol, illegal drugs, or drug paraphernalia
- No persistent, disruptive behavior
- Everyone must contribute to the operation and maintenance of the Homestead.
I will be a positive member of this community and contribute toward making it a safe, secure, clean and pleasant place to live.
Therefore I agree to the following:
- What I do will be based on love and respect for myself and others.
- I will not disrespect others based on ethnicity, religion, gender, sexual orientation, handicap, lifestyle choices, or economic status. We all have the right to expect dignity and opportunity.
- I will help make HFH a place where everyone feels safe and respected. For my own safety as well as the safety of others, I will not carry a weapon or act violently toward others or myself.
- Since stealing is one of the most upsetting things that can happen in our community, I will not steal and will make the members of the Homestead Council aware of any stealing I see. I will respect other people’s property and community property and I expect other people to respect mine.
- I know that illegal drugs and alcohol use can damage my community. I agree not to use illegal drugs or alcohol while at the Homestead.
- I will honor quiet hours from 10PM to 7AM so that others and myself can stay healthy and rested. I understand that no personal guests will be allowed during that time.
- I want to live in a clean, litter-free, comfortable space where I can bring friends, family and other guests. Also, I know that many communities such as ours get closed down for “health and safety” reasons. I will keep the area in and around where I live clean and orderly, and not store any personal items outside of my building footprint or allocated storage space. I will help keep the community areas clean and will pick up after myself and my pet, if I have one, and keep my pet leashed at all times. I understand that only a limited number of pets will be allowed in the Homestead in order to maintain an orderly environment.
- I understand that in order to maintain a secure environment there will be a single point of entrance and exit that will be staffed 24/7, and that security shifts will be shared equally among Homestead residents.
- I know that it can take a lot of work to keep the Homestead a safe, clean and pleasant place to live. I agree to work at least 10 hours a week on the operation and maintenance of the Homestead. This includes serving on security teams, helping with kitchen duties, construction projects, maintenance and clean-up crews, helping plan activities and other jobs that need to be shared by community members.
- I also know that there are financial costs to keep the Homestead running. I will support the goal of self-sufficiency by contributing each month either financially or through sweat equity by participating in micro-business opportunities or fundraising events.
- I will attend the weekly Homestead meetings, unless I have an acceptable reason for absence, in which case I will find out what went on by reading the meeting notes. I understand that decisions will be made through a majority vote, and that the Board of Directors of the non-profit reserves the right to override decisions made. I agree to abide by all decisions made.
- I affirm that I have completed the Background Check Form honestly along with all other application documents. I understand that if the background check reveals otherwise, I could be asked to leave immediately.
I promise to keep all of these agreements, as well as others that are approved at Homestead meetings. If I violate any agreements, the members of the Homestead Council are authorized to ask me to leave temporarily, or, in serious or repeat cases, to leave permanently. I will do so peacefully and not return unless I am authorized to do so.
I know that HFH is a place where people value community and support each other. I will try to think of ways to make our community a better place to be. When I am concerned or upset with situations in the Homestead, I will bring these problems to the attention of the appropriate people so that we can work together to figure things out. I willingly sign these agreements that are a contract between Homes for Hearts and me.
Name (Signature): _____________________________________________________
Date: __________________________
Homes for Hearts (HFH) Application & Intake Questionnaire
Date: __________________ Legal/Given Name: __________________________________________________________________
Name Used: ________________________________________________________________________
Race/Ethnicity: ______________________ Gender: ___________________
Driver’s License/State ID number: ________________________ State issued: __________
How do we contact you?
Location: ________________________________________________
Phone: __________________________________________________
Email: ___________________________________________________
Where did you sleep last night: ____________________________________________________________________________
Date of birth: _____________________ Circle one: Single / Married / Partnered
Is your spouse/partner applying to HFH? Yes / No
If so, spouse/partner’s name:_____________________________________________________
Do you have children with you? Yes / No If so, how old are they? ___________________
Do you have a car? Yes / No Do you have an RV? Yes / No
How much stuff do you have? Backpack / Car load / Truck load / Storage Unit
Do you have a pet? Yes/No
If so, what kind? _____________ How many pounds? _____________ Spay/neuter? Yes/No
- How did you become unhoused? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- How long have you been without stable housing? _________________________________________
- Where was your most recent permanent address? _________________________________________
- How long have you been in the Memphis/Tennessee Area? __________________________________
- Is this your first experience being unhoused? ____________________________________________
- Do you have a source of income? Yes / No If so, what source? ___________________________
- Do you get food stamps? Yes / No If not, do you want help applying? Yes / No
- Are you on OHP? Yes / No If not, do you want help applying? Yes / No
- Do you receive SSI/SSDI? Yes / No If not, do you want help applying? Yes / No
- Are you on any housing lists? Yes / No If so, which? ______________________________
________________________________________ If not, do you want help applying? Yes / No
- Have you been active in houseless issues/activism? Yes / No If so, how? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Have you ever lived in a rest stop, homeless village or other community environment? Yes / No
If so, which one and for how long? ________________________________________________
- Are you a veteran? Yes / No Branch: _______________ Type of discharge: __________
- Are you employed? Yes / No If so, where and how many hours/week? ________________________________________________________________________________________________________________________________________________________
- Do you have a disability or special needs? Yes / No If so, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Female head of household? Yes/No
- Elderly head of household (over 65)? Yes/ No
- What goals do you have for yourself? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Is there anything you would like to tell us about yourself? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Skills Inventory
- How far have you gone in school? _____________________________________________________
- What did you study? _______________________________________________________________
- Any plans to go back to school? Yes / No To study what? ________________________________
- Have you worked for pay? Yes / No If so, what kinds of work have you done?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- What is the best job you ever had? ____________________________________________________
Why? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- What are your hobbies? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
7.What of the following do you have experience with? (Check all that apply)
Rough Carpentry____
Finish Carpentry ____
Plumbing ____
Electrical ____
Gardening ____
Farming ____
Security (Military/Law enforcement/Private) ____
Permaculture ____
HVAC ____
Inventing ____
Masonry ____
Driver ____
Mechanic/small engine repair ____
Chimney Sweeping ____
Roofing ____
Cooking/Food Service ____
Computers, Web Development ____
Computers, Word ____
Processing/Spreadsheets ____
Computers, Data Entry ____
Computers, Desktop publishing ____
Writing ____
Business owner ____
Activism/Community Organizing ____
Management ____
Community/Political Leader ____
Masonry ____
Spiritual Leadership ____
Sales ____
First Aid ____
Bookkeeping/managing money ____
Computers, Programing ____
Office Manager ____
Other: ________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
8.Things you are interested in contribution to Homestead life:
Creative/Artistic ____
Communications/Outreach ____
Drawing, Illustration ____
Speaking/Presenting to groups ____
Writing – Promos, ads… ____
Filing ____
Stuffing Envelopes ____
Sewing/knitting ____
Coordination Volunteers ____
Bookkeeping/Accounting ____
Computer repair ____
Legal/Paralegal ____
Specific Software ____
Electrical ____
Medical/first aid (list certification) ____ / _________________________
Sign making/painting ____
Desktop publishing ____
Computer Graphics ____
Office and Administrative ____
Performance – acting, music, dance… ____
Cooking ____
Phone Calls ____
Computers ____
Networking ____
Note take, keeping minutes ____
Data Entry ____
Technical ____
Driving (list license type) ____ / ____________________
Carpentry ____
Plumbing ____
Roofing
Drafting/reading technical plans
Masonry
Leading work parties
Painting
Glazing
Landscaping
Gardening
Labor
Other: ________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Please provide an Emergency Contact:
____________________________________ _______________ _______________ Name Phone Relationship
Homes for Hearts (HFH) Background Check Form
Notice: We will conduct a background check on all applicants. If that background check does not match your answers on this form, your application to live in Homes for Hearts will be denied. The only criminal offenses that automatically exclude are forcible/aggravated rape and sexual predation on children. PLEASE BE HONEST!
Last Name: ______________________ First Name: ______________________
Middle Name: ______________________
Date of Birth: ______________Last 4 digits of SSN:______________
Have you ever been convicted of a criminal offense? Yes / No
If yes, please state the City/Town, County and State, the date of the conviction, and charges you were convicted of. (Please use the back of the sheet if you need more room).
- __________________________________ / _______________
City, State, County Date/Yr
____________________________________________________________________________
Offense
- __________________________________ / _______________
City, State, County Date/Yr
____________________________________________________________________________
Offense
- __________________________________ / _______________
City, State, County Date/Yr
____________________________________________________________________________
Offense
The information on this form is true and accurate to the best of my knowledge. I give permission to verify all information provided.
__________________________________________________ / ________________________ Applicant Signature Date
__________________________________________________ / ________________________
HFH Representative Date