Resident Intake Form

Please complete the form below and tap Submit at the bottom. It takes about 5 minutes. Questions marked (optional) can be left blank.

Need help? Call (954) 945-9711 and we will be glad to assist you. Prefer paper? Download the printable form.

Applicant Information

Full legal namePlease enter your full name.

Date of birthPlease enter your date of birth.

Phone numberPlease enter a phone number.

Email address (optional, we will email you a confirmation)Please check your email address.

Current addressPlease enter your current address.

Emergency Contact

Contact namePlease enter a contact name.

Relationship to youPlease enter the relationship.

Phone numberPlease enter a phone number.

Email address (optional)Please check the email address.

Move-In Details

Current living arrangementPlease describe your current living arrangement.

Shared living space / roommate (optional)

Support & Referral

Optional. Your answers here do not affect your application.

Are you currently working with a case worker or receiving help from a program?

YesNo

Case worker name

Agency or program name

Case worker phone

Case worker emailPlease check the email address.

May we contact your case worker about your application?

YesNo

Acknowledgment & Signature

I understand that Keep On Living Housing provides independent living housing only. No personal care, medical assistance, or supervised services are provided.Please check this box to continue.

Type your full name as your signaturePlease type your full name to sign.

By typing your name and submitting, you confirm the information above is true and complete to the best of your knowledge.

Your information is sent securely to Keep On Living Housing and used only to review your application.

Thank you! Your form was received.

We will review your information and contact you to schedule your interview. If you have any questions, please call (954) 945-9711.

If you provided an email address, a confirmation has been sent to your inbox. Please check your spam or junk folder if you don't see it.

Return to the website