Autumn House Pre-Application Form

This form must be signed by ALL adult members of the household and returned to:

Autumn House does not discriminate on the basis of disability status in the admission or access to, or treatment, or employment in, its federally assisted programs and activities.

Date:

Name:

Address:

City/State/Zip:

Phone:

FAMILY COMPOSITION

List all persons who will be living in your home. (Please remember to include yourself)

Family Member Name #1 (First, MI. Last)

Birth Date:

Social Security Number:

Relationship:

Age:

Sex:

Birthplace (City/State):

Race: WhiteBlackAmerican Indian or AlaskanAsian or Pacific

Ethnicity: HispanicNon-Hispanic

Family Member Name #2 (First, MI. Last)

Birth Date:

Social Security Number:

Relationship:

Age:

Sex:

Birthplace (City/State):

Race: WhiteBlackAmerican Indian or AlaskanAsian or Pacific
Ethnicity: HispanicNon-Hispanic

Family Member Name #3 (First, MI. Last)

Birth Date:

Social Security Number:

Relationship:

Age:

Sex:

Birthplace (City/State):

Race: WhiteBlackAmerican Indian or AlaskanAsian or Pacific
Ethnicity: HispanicNon-Hispanic

Anticipated Changes in Family Composition:

Have you or any household member resided in any other state(s)
YESNO

If yes, please list the state(s) and household members that resided in those state(s) below: