Independent Living Program Application & Rule Acknowledgment

Please be advised that all residents are responsible for a monthly housing fee that can range from $850-$1250 per bed. Payment is required regardless of benefit status (SSI, SSDI, employment, VA benefits, etc.) and must be paid in full according to the lease terms. If you are receiving rental assistance or financial support from any agency, program, case manager, or third party, you remain fully responsible for ensuring that Dedicated Hands receives payment on time each month. It is your responsibility to verify that all payments are processed and delivered as agreed. Failure of an outside agency or program to submit payment does not relieve you of your financial obligation. By submitting this application, you acknowledge and agree to these terms.

Applicant's First Name *

Applicant's Last Name *

Phone *

Email *

Date of birth *

Identification 1 *

Driver's License

State ID

Passport ID

Upload Identification 1 *

PDF, DOCX, DOC, JPEG, JPG or PNG

Identification 2

Social Security Card

Birth Certificate

Do Not Have

Upload Identification 2

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Monthly Income Amount *

Anticipated Move-In Date *

What Agency Referred you? *

IMPORTANT – PLEASE READ BEFORE COMPLETING THIS APPLICATION.

IMPORTANT – PLEASE READ BEFORE COMPLETING THIS APPLICATION. You must agree to ALL program rules below before we can proceed with screening. If you do not agree, do not continue this application.

REQUIRED RULE ACKNOWLEDGMENT (Must Complete Before Application)

Rule 1: No violence, threats, or disrespectful behavior of any kind.

I Understand and Agree *

Required: check to indicate you understand and agree to this rule.

Rule 1: Initials *

Rule 2: No illegal substances or alcohol allowed on the property at any time.

I Acknowledge and Agree *

Required: Check the box to acknowledge and agree to this rule.

Rule 2: Initials *

Rule 3: No overnight guests are permitted.

I Confirm and Agree

Required: Check the box to confirm your understanding and acceptance of this rule

Rule 3: Initials *

Rule 4: Visitors must remain in common areas only.

I Have Read and Agree *

Required: Please check the box to indicate that you have read, understood, and agree to this rule.

Rule 4: Initials *

Rule 5: Residents are responsible for the behavior of their visitors.

I Accept and Agree *

Required: By checking the box, you confirm that you understand and agree to this rule.

Rule 5: Initials *

Rule 6: Curfew will be enforced and must be inside by designated curfew time and is expected to respect all structured house hours.

I Acknowledge and Accept *

Required: Check the box to acknowledge that you understand and accept this rule.

Rule 6: Initials *

Rule 7: All areas must be kept clean and organized at all times.

I Have Read, Understood, and Agree *

Required: Check the box to confirm your understanding and agreement to this rule.

Rule 7: Initials *

Rule 8: Laundry is allowed once per week either Tuesday or Thursday (last wash 8 PM).

I Confirm That I Understand *

Required: Please check the box to acknowledge that you understand and agree to this rule.

Rule 8: Initials *

Rule 9: Only 4 bags of clothing or personal items allowed upon move-in.

I Agree to the Terms *

Required: Check the box to indicate your acknowledgment and acceptance of this rule.

Rule 9: Initials

Rule 10: Smoking, vaping, and drug use are prohibited inside the property. Smoking only allowed in designated outdoor areas.

I Acknowledge the Terms and Conditions *

Required: Please confirm that you have read, understood, and agreed to this rule by checking the box.

Rule 10: Initials *

Rule 11: Failure to pay rent or program fees will result in termination.

I Have Read and Accept the Terms *

Required: Check the box to acknowledge and confirm your compliance with this rule.

Rule 11: Initials *

Rule 12: Repeated violations may result in termination from the program.

I Have Read, Understood, and Agree to the Terms *

Required: Check the box to acknowledge that you understand and accept this rule

Rule 12: Initials *