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808-737-7995
The Arc in Hawaii
Inclusion. Involvement. Independence.
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808-737-7995
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ABOUT US
History of The Arc in Hawaii
Core Values and Operating Principles
Strategic Plan
Board of Directors
SERVICES
Eligibility for Services
Adult Health Service
Residential Services
ADVOCACY
EMPLOYMENT
DONATE
FORMS
Application For ADH Services
Application for Residential Services
CONTACT US
HOME
ABOUT US
History of The Arc in Hawaii
Core Values and Operating Principles
Strategic Plan
Board of Directors
SERVICES
Eligibility for Services
Adult Health Service
Residential Services
ADVOCACY
EMPLOYMENT
DONATE
FORMS
Application For ADH Services
Application for Residential Services
CONTACT US
Application for Residential Services
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Home
Application for Residential Services
Application for Residential Services
Residential Application
Applicant’s Name
(Required)
First
Middle
Last
Date of birth
(Required)
MM slash DD slash YYYY
Sex
Male
Female
Non-Binary
Social Security#
Citizenship
Medicaid#
Phone
(Required)
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Is Any Household Member Enrolled in an institute of Higher Education?
(Required)
Yes
No
Please list all the other states applicant has resided in:
Is Any Household Member A Registered Lifetime Sex Offender in Any State?
(Required)
Yes
No
Are you or your co-applicant contending eligible immigration status?
(Required)
Yes
No
If yes. Social Security Numbers need to be disclosed for all applicants.
Name
(Required)
SSN#
(Required)
If you were 62 or older on 1/31/2010 and don’t have a Social Security Number, were you receiving HUD rental assistance at another location on 1/31/2010?
Yes
No
Current Living Situation (check):
(Required)
Family
Domiciliary Home for Developmental Disabled Adults
Foster Home
Currently Occupying HUD Assisted Unit
ICF/IDD-C Home
Other
Legal Guardian’s Name
Relationship/Title
Phone
Email address
(Required)
Case Manager’s Name
Agency
Phone
Email address
(Required)
Family Information:
Father’s Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Work Phone
Email Address
(Required)
Mother’s Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Work Phone
Email Address
(Required)
Applicant’s Condition (s) (check all that apply):
Intellectual Developmental Disability (IDD) (degree of impairment):
Autism
Cerebral Palsy
Epilepsy
Learning Disability
Visual and/of Hearing Impairment (degree of impairment):
Physically aggressive towards others (explain):
Self-injurious behaviors (explain):
Adaptive Protective Equipment Needed (e.g., furniture, wheelchair, crutches, etc.)
Education, Training, and Employment History (list last school or program first):
1.
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
2.
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
3.
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Financial Support (list monthly amount received in each category as appropriate)
Family
Family
SSI
Trust
Job
Other
Eligible for Medicaid
Eligible for Waiver Services
Services That You Are Applying For (check all that apply):
ICF/IDD-C Home (24-hour awake staff who provide medical and behavioral support)
Domiciliary (home type of environment, but without 24-hour awake staff)
Apartment (independent living with minimal support)
How did you hear about our services (i.e., Case Mgr., website, ad, etc.)?
Contact Information: I certify that the information provided is complete and accurate.
Name
Phone
Relationship to Applicant
Signature
Applicant Signature
Date
MM slash DD slash YYYY
Applicant’s Name
Race and Ethnic Data Reporting Form
U.S. Department of Housing and Urban Development Office of Housing
OMB Approval No. 2502-0204 (Exp. 06/30/2017)
Name of Owner/Managing Agent
Type of Assistance or Program Title
Name of Head of Household
Name of Household Member
Date
MM slash DD slash YYYY
Ethnic Categories
(Required)
Hispanic or Latino
Not-Hispanic or Latino
Racial Categories
(Required)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
Applicant Name
Mailing Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Telephone No
Cell Phone No
Name of Additional Contact Person or Organization
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Telephone No
Cell Phone No
E-Mail Address (if applicable)
Relationship to Applicant
Reason for Contact
Emergency
Assist with Recertification Process
unable to contact you
Change in lease terms
Termination· of rental assistance
Change in house rules
Eviction from unit
Late payment of rent
Other
AUTONOMY CHECKLIST
MEDICAL
1. Can safely administer and store own medication without supervision
Yes
No
With Assistance
2. Can administer emergency first aid
Yes
No
With Assistance
3. Is aware of signs of personal illness and can request assistance
Yes
No
With Assistance
4. Can handle routine illness with minimum support
Yes
No
With Assistance
5. Can keep doctor’s appointments
Yes
No
With Assistance
6. Can follow routine medical instructions
Yes
No
With Assistance
Comments
EMERGENCY
1. Can recognize an emergency and respond appropriately
Yes
No
With Assistance
2. Can evacuate in case of emergency, when necessary
Yes
No
With Assistance
3. Can dial emergency number an request assistance
Yes
No
With Assistance
4. Can understand and follow verbal instructions
Yes
No
With Assistance
Comments
PERSONAL SKILLS
1. Can have a house key
Yes
No
With Assistance
2. Can go shopping
Yes
No
With Assistance
3. Can manage personal grooming (bath, shower, wash hair)
Yes
No
With Assistance
4. Can choose appropriate clothes to wear
Yes
No
With Assistance
Comments
HOUSEKEEPING
1. Can clean own room
Yes
No
With Assistance
2. Can make the bed/change the bedding
Yes
No
With Assistance
3. Can choose decorations for the room
Yes
No
With Assistance
4. Can do minor household repairs (change light bulb)
Yes
No
With Assistance
5. Can take out the trash
Yes
No
With Assistance
6. Can do basic sewing/mending
Yes
No
With Assistance
Comments
NUTRITION
1. Can plan a menu
Yes
No
With Assistance
2. Can purchase food
Yes
No
With Assistance
3. Can operate appliances (stove, oven, microwave)
Yes
No
With Assistance
4. Can use common kitchen tools (can opener, knife, measuring cup, grater, etc.)
Yes
No
With Assistance
5. Can follow a recipe or make a meal
Yes
No
With Assistance
6. Can set the table
Yes
No
With Assistance
Comments
LAUNDRY
1. Can put dirty clothes in hamper
Yes
No
With Assistance
2. Can sort clothes
Yes
No
With Assistance
3. Can use washer and dryer
Yes
No
With Assistance
4. Can iron clothes
Yes
No
With Assistance
5. Can hand wash clothes
Yes
No
With Assistance
6. Can fold clothes
Yes
No
With Assistance
7. Can put clothes away
Yes
No
With Assistance
Comments
FAMILY INTERACTION
1. Can watch TV and discuss with family members
Yes
No
With Assistance
2. Can help take care of siblings
Yes
No
With Assistance
3. Can participate in family decisions
Yes
No
With Assistance
4. Can plan family outings
Yes
No
With Assistance
5. Can take care of pets
Yes
No
With Assistance
Comments
SANITATION SAFETY
1. Can prepare and store food safely
Yes
No
With Assistance
2. Can handle waste disposal in a sanitary/safe fashion
Yes
No
With Assistance
3. Can wash dishes and/or pots and pans
Yes
No
With Assistance
4. Can maintain personal sanitation and hygiene
Yes
No
With Assistance
Comments
PERSONAL SAFETY
1. Can take responsibility for self when away from home
Yes
No
With Assistance
2. Can take responsibility for and secure home and personal belongings
Yes
No
With Assistance
3. Can use and maintain electrical and household appliances safely
Yes
No
With Assistance
4. Can take responsibility for own sexual behavior
Yes
No
With Assistance
Comments
FINANCIAL
1. Can manage own money and/or bank account
Yes
No
With Assistance
2. Can plan for use of money and make personal purchases
Yes
No
With Assistance
3. Can be responsible for management and use of Food Stamps
Yes
No
With Assistance
Comments
TRANSPORTATION
1. Can routinely transport self independently (e.g. can use The Bus, Handivan, Handicab, or other means of transportation without assistance)
Yes
No
With Assistance
2. Can request assistance, ask directions, or use telephone when necessary
Yes
No
With Assistance
Comments
50894
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