Share Foundation

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Applicant Information

First Name

Last Name

Mobile Number

Email (Family/ Contact's)

Address

City

State

Zip

Date of Birth

Social Security Number

Sex

Height

Weight

With whom is the applicant currently residing?

Is the applicant currently enrolled in any school programs?

If yes, where?

Family Info

Father's Name (First, Middle Initial, Last)

Father's Date of Birth

Father's Address

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Father's Phone Number

Father's Social Security Number

Father's Email

Mother's Name (First, Middle Initial, Last)

Mother's Address

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Mother's Phone Number

Siblings (Full Names & Ages)

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Does the applicant have a guardian?

If yes, please give name and relationship to applicant.

Please give THREE (3) references for the guardian. [Include name & contact info]

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Financial Information

Does the applicant receive Social Security or SSI? (mark all that apply)

Social Security

SSI

Monthly Amount:

Is there any additional income?

If yes, please describe.

Is the applicant on Medicare, Medicaid or Private Health Insurance?

(Mark all that apply)

Medicare

Medicaid

Private Health Insurance

Insurance Company Name:

Policy Number:

Insurance Campany Address:

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Applicant's History

Description of applicant's disability:

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Doctor's Name:

Doctor's Phone Number:

Doctor's Address:

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Describe any medical attention the applicant is now receiving, including medication and therapies:

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List schools applicant attended, beginning with most recent (School Name, City/State, Type of Training, Highest Grade): :

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List jobs applicant has held, beginning with most recent (Employer, City/State, Job Title, Dates Employed):

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List any previous residential placements (group homes, etc.) the applicant has had:

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Applicant's Personal Information

List applicant’s personal strengths:

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List applicant’s weaknesses:

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What characteristics could benefit from growth and development?

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What are the applicant’s hobbies and interests?

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What is the applicant’s religious affiliation?

What are your expectations of residency at Sharing Meadows?

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Does the applicant have any other residential alternatives?

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I have read and agreed that the above statements are true and correct to the best of my knowledge.

Name of Person Filling Out Form:

Relationship to Applicant:

Today's Date:

All information will be held in strict confidence.

Applicant Information

Family Info

Financial Information

Applicant's History

Applicant's Personal Information

Donation amount