First Name*
Last Name*
Email Address*
Phone*
Are you 18 years of age or older?*
No answer Yes No
Current County of Residence:*
-- No answer -- Franklin County Delaware County Licking County Fairfield County Other
Do you currently reside in the Central Ohio Region? If you live in Columbus or in the immediately surrounding areas, you're most likely in Central Ohio. Please be aware that our program currently only serves families in the Central Ohio Region.*
-- No answer -- Yes, I live in Columbus or the surrounding area No, I live in other parts of Ohio outside of the Columbus area
Marital Status:*
-- No answer -- Single Divorced Separated Widow In a Relationship Married
Gender:*
-- No answer -- Female Male Nonbinary / other
Date of Birth:*
What is your highest educational attainment?*
-- No answer -- Less than High School High School Diploma or GED Some College 2 Year College Degree 4 Year College Degree or Beyond Certificate or Trade School
Are you currently enrolled in school? If so, describe your school situation (where do you go, is it full-time or part-time, degree program, etc.)*
What is your household type? Please be aware that you need to have at least one child in your household to qualify for this program.*
-- No answer -- Single parent and children Two parents and children Parent and partner jointly raising children Other relative or guardian(s) and children Adult(s), no children
Applicant 2: Full Name
Applicant 2: Email Address
Applicant 2: Phone Number
Applicant 2: Date of Birth:
Applicant 2: Gender
-- No answer -- Female Male Nonbinary / other
Applicant 2: Marital Status
-- No answer -- Single Divorced Separated Widow In a Relationship Married
Applicant 2: What is your highest educational attainment?
-- No answer -- Less than High School High School Diploma or GED Some College 2 Year College Degree 4 Year College Degree or Beyond Certificate or Trade School
Applicant 2: Are you currently enrolled in school? If so, describe your school situation (where do you go, is it full-time or part-time, degree program, etc.). If not enrolled in school, please type "Not Applicable"
Do you own your own house? If you own your own home, you are not eligible for the Families Flourish program.*
-- No answer -- Yes No
Have you or your partner (if applicable) had a prior eviction? Prior evictions will not automatically eliminate you from consideration for the program. If so, please list how many and when they occurred;*
Do you rent?*
-- No answer -- Yes No
If you answered "No" to BOTH owning a home AND renting please describe your housing situation, OR type "Not Applicable"*
Monthly Rent:*
Monthly Utilities:*
How long have you and your partner (if applicable) lived at your current address? If the length of time is different for each partner please list;*
Do you or your partner (if applicable) currently have a housing choice voucher, previously known as the section 8 program? Please note: This voucher cannot be used in this program.*
-- No answer -- Yes No
How soon are you able to move in? Please be aware that this application is for moving between March and July 2026 and we are not able to accommodate moves outside of this time frame.*
Do you or applicant 2 have a valid driver's license?*
-- No answer -- Yes, applicant 1 has a valid Driver's License Yes, applicant 2 has a valid Driver's License Yes, both applicant 1 and 2 both have a valid Driver's License No, no adult in the household has a valid Driver's License
Do you have a working car?*
-- No answer -- Yes, applicant 1 has a working car Yes, applicant 2 has a working car Yes, both applicants 1 and 2 both have their own working car No, no adults in the household have a working car
Does applicant 2 have a different rental history than applicant 1?*
-- No answer -- Not Applicable Yes No
Previous Address*
How long did you live at your previous address?*
-- No answer -- Less than 6 months 7 months to 1 year 1 - 2 years 2 years or more
Previous Monthly Rent:*
Do you or your partner (if applicable) have any past due balances with landlords or utilities?*
-- No answer -- Yes No
For past due balances, please list who is owed and how much. Please be aware that this is a requirement for our program that all past due balances of this nature have been paid off. If no past due balances, write "not applicable".*
In our program, each approved family is provided a list of apartments to choose from in communities high in resources. Each approved family moves into an apartment with one of these landlords. This is required to be part of our program. Are you (both, if applicable) willing to do this?*
-- No answer -- Yes No
How many children are in your household? Please be aware that 3 children in the home is the maximum allowed for our program.*
-- No answer -- 0 1 2 3 4 or more
Child Name 1:*
Child 1's Gender:*
-- No answer -- Male Female Nonbinary / other
Child 1's Date of Birth (Or Due Date if pregnant):*
Child 1's School/Daycare:*
Child Name 2:
Child 2's Gender:
-- No answer -- Male Female Nonbinary / Other
Child 2's Date of Birth (Or Due Date if pregnant):
Child 2's School/Daycare:
Child Name 3:
Child 3's Gender:
-- No answer -- Male Female Nonbinary / Other
Child 3's Date of Birth (Or Due Date if pregnant):
Child 3's School/Daycare:
Do you have children not currently living with you? If so, please list their name, age, and living arrangements.
Health Insurance for Child(ren):*
-- No answer -- Medicaid Insurance through Employer Private Insurance Uninsured Other
Do you have custody of your child(ren) in your household? Check ALL that apply.*
Our program requires that your school-aged children would attend the public school in the neighborhood where you would move to. Do you (both, if applicable) agree to this?*
-- No answer -- Yes No This does not apply to me, as my child(ren) will not be school aged in the next 3 years.
Are you (both, if applicable) willing to meet monthly with a life coach for 3 years? Please be aware that this is a requirement for our program.*
-- No answer -- Yes No
Are you (both, if applicable) willing to attend one program every month (primarily virtually) for 3 years on Tuesday evenings? Please be aware that this is a requirement for our program.*
-- No answer -- Yes No
Are you (and/or your partner) currently employed? Please be aware it is a requirement for our program that all adults in the household are employed.*
-- No answer -- Applicant 1 is employed Applicant 2 is employed Applicant 1 and 2 are employed Applicant 1 and 2 are unemployed Applicant 1 is unemployed, but is in school full time Applicant 2 is unemployed, but is in school full time Applicant 1 is unemployed and is NOT in school full time Applicant 2 is unemployed and is NOT in school full time
We accept non-wage income along with earned income. Which of these sources of non-wage income do you have?*
Applicant 1 - 1st job: Current Employer:*
Applicant 1 - 1st job: Current Position/Title:*
Applicant 1 - 1st job: Current Employer Address Please enter: Street City, State Zip*
Applicant 1 - 1st job: Current Yearly Earned Income or Yearly Salary:*
Applicant 1 - 1st job: Current Hourly Amount:*
Applicant 1 - 1st job: Hours per week:*
Applicant 1 - 1st job: Start Date:*
Applicant 1 - 2nd job: Current Employer:
Applicant 1 - 2nd job: Current Position/Title:
Applicant 1 - 2nd job: Current Employer Address Please enter: Street City, State Zip
Applicant 1 - 2nd job: Current Yearly Earned Income or Yearly Salary:
Applicant 1 - 2nd job: Current Hourly Amount:
Applicant 1 - 2nd job: Hours per week:
Applicant 1 - 2nd job: Start Date:
Applicant 1 - Previous job: Employer:*
Applicant 1 - Previous job: Position/Title:*
Applicant 1 - Previous job: Employer Address Please enter: Street City, State Zip*
Applicant 1 - Previous job: Yearly Earned Income or Yearly Salary:*
Applicant 1 - Previous job: Hourly Amount:*
Applicant 1 - Previous job: Hours per week:*
Applicant 1 - Previous job: Start Date:*
Applicant 1 - Previous job: End Date:*
Applicant 2 - 1st job: Current Employer:
Applicant 2 - 1st job: Current Position/Title:
Applicant 2 - 1st job: Current Employer Address Please enter: Street City, State Zip
Applicant 2 - 1st job: Current Yearly Earned Income or Yearly Salary:
Applicant 2 - 1st job: Current Hourly Amount:
Applicant 2 - 1st job: Hours per week:
Applicant 2 - 1st job: Start Date:
Applicant 2 - 2nd job: Current Employer:
Applicant 2 - 2nd job: Current Position/Title:
Applicant 2 - 2nd job: Current Employer Address Please enter: Street City, State Zip
Applicant 2 - 2nd job: Current Yearly Earned Income or Yearly Salary:
Applicant 2 - 2nd job: Current Hourly Amount:
Applicant 2 - 2nd job: Hours per week:
Is there anything else you’d like to add about your situation that was not covered in the above questions? If not, write "Not applicable."*
Referral Source? (How did you hear about Families Flourish?)*
-- No answer -- Social worker/Case worker (please indicate the organization/program they work with below) Friend or Relative who is/was in the Families Flourish program (please indicate the person's name below) Friend or Relative NOT in the Families Flourish program Internet Search Medical care worker: nurse, doctor, etc. (please indicate the organization/program they work with below) Employment Center (please let us know which center below) Daycare (please indicate which daycare below) Counselor (please indicate which agency or organization below) Coach/Teacher (please indicate which school/organization below) Event/Fair (please indicate which event or fair you attended below) Employer (please indicate the name of your employer below) Social Media (please indicate which site: Facebook, Instagram, etc below.) Newspaper Other
Please provide more information about your referral source (organization, program, name, etc.)*
Applicant 1: I acknowledge the information I provided on this form is true and correct. Please type your signature and date you signed.*
Applicant 2: I acknowledge the information I provided on this form is true and correct. Please type your signature and date you signed.*
Demographic information is used to determine if our equal opportunity efforts are reaching all segments of the population. Responses to the below questions are voluntary. Your responses will not be placed in your file nor will they be provided to your landlord should you be approved for our program. Aggregate demographic information collected from all clients will be available to the program's funders and the public, but neither your identity nor your individual responses will be disclosed.*
-- No answer -- Yes No
Hispanic Origin:*
-- No answer -- Hispanic Non-Hispanic Prefer Not To Answer
Race/Ethnicity*
-- No answer -- American Indian or Alaska Native Asian Black or African American Caucasian / White Middle Eastern or North African Native Hawaiian or Other Pacific Islander Other Two or More Races Prefer Not to Answer
Applicant 2: Hispanic Origin
-- No answer -- Hispanic Non-Hispanic Prefer Not to Answer
Applicant 2: Race/Ethnicity
-- No answer -- American Indian or Alaskan Native Asian Black or African American Caucasian / White Middle Eastern or North African Native Hawaiian or Other Pacific Islander Other Two or More Races Prefer Not to Answer
