New Roots Housing Project

Application Form
Date of Application






Worksop           Retford          Harworth


Please indicate which areas you wish to be considered for
Which Scheme are you applying for?
Shared          Move On          Young Parent          Floating Support for Young Parents
(Young parent and floating support applicants please complete additional page below)
Applicant's Details
First Name (s)
Last Name
Are you, or have you, been known by any other name?
What do you prefer to be called?
Date of birth                                               
Age
Male          Female
National Insurance Number
Your telephone number
Name and number where message may be left
Where do you live now?
Family Home          Friends          Own Tenancy          B&B

Sleeping Rough          with Partner/ former Partner          Other
If other please give details
Current address
How long at current address
From                                               To
Can we contact you at the above address?
Yes          No
Please explain the reason for leaving or the need for accommodation
Have you been given a date to move
Yes          No
If Yes please state
Have you had a tenancy with New Roots or made a previous application?
Yes          No
Previous Addresses
Please give details of your last three addresses starting with the most recent
Address 1
From                              To
Type of accommodation and with whom
Reason for leaving
Address 2
From                              To
Type of accommodation and with whom
Reason for leaving
Reason for leaving
From                              To
Type of accommodation and with whom
Address 3
Status
Are you employed?                   Yes          No

On a training scheme?              Yes          No

In education?                              Yes          No
Who with or where

Who with or where

Who with or where
Which benefit are you in receipt of?
When did this benefit start?
How much do you receive?
Current salary if working
Health Information
Name of Doctor
Address of Surgery
Tel
Are you on any medication?
Yes               No
If Yes please give details
Do you have any health problems or disabilities that the project needs to be aware of?
Yes               No
If Yes please give details
Social Welfare
Please be honest in the answers you give, your past will not necessarily affect your application
Do you have support from another agency? e.g. Framework, Social Services, Probation, Other
Yes               No
If Yes please give name of Key Worker
Have you ever been involved with the police or been subject to a probation order?
Yes               No
If Yes please give details of any past or pending offences including:
Arson, Violence, Sexual Offences, Theft, Drug Offences.
Please be honest in the answers you give, your past will not necessarily affect your application. This question is being asked to ensure than an appropriate level of support can be offered to meet your needs.
Are you using, or have you used (in the last 6 months)
DRUGS                                      YES                 NO

SOLVENTS                                YES                 NO

EXCESSIVE ALCOHOL               YES                 NO
If you are receiving help with this please give details.
Who would you want us to contact in an emergency
Name
Relationship to you. i.e. relative, friend
Contact address
Who is your next of kin?
Contact address
Are you on a housing waiting list?
Yes               No
With whom?
A1 Housing

Letts

Other
How long have you been on this waiting list?
Additional page for Young Parent Application
Please complete this section only if you are applying for a place in the Young Parent scheme
Name of applicant
Address
Expected date of delivery dd/mm/yy
Midwife
1st child's name                                            Girl           Boy                    DOB

2nd child's name                                           Girl           Boy                    DOB
Social Worker for baby / child
Health Visitor
Doctor's Surgery
Yes               No
Yes               No
Yes               No
Yes               No
Yes               No
Any problems during / with pregnancy?
If Yes please give details
Does baby / child have any medical problems, conditions or disabilities we need to be aware of?
If Yes please give details
Has baby/ child been prescribed any medicines?
If Yes please give details
Do you or your baby/ child attend any of the following?
Ante Natal          Teenage Parenting Group          Parent and Toddler Group

Albion Centre          Nursery          Playgroup          Parentzone

Other
If other please give details
Do you receive any support or help from baby's / child's grandparents or any other relatives?
If yes please give details
Father's name (mother's name if father is the applicant)
Address
Does the other parent have contact with baby / child?
If yes please give details / arrangements
What are your specific concerns around your current housing situation?
Equal Opportunities Monitoring
Please tick relevant box
White

British          Irish          Gypsy / Romany          Other White

Mixed

White & Black Caribbean          White & Black African          White & Asian          Other Mixed

Asian or Asian British

Indian          Pakistani          Bangladeshi          Other Asian

Black or Black British

Caribbean          African          Other Black

Other Ethnic Group

Chinese          Other Please Specify                                                        Prefer not to say





Declaration

In order to process your application New Roots may find it necessary to contact other agencies for information. This may include Social Services, Local Authorities, housing associations and or landlords, the Police etc.

The information I have given is true and complete. I hereby give my permission for New Roots to contact any relevant agencies including present and previous landlords. I authorise such agencies to disclose any information requested by New Roots in order to process my application and assess relevant support needs.


I Agree                                                            I Do Not Agree
Traveller