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?*
-- No answer -- Yes No
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?*
-- 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?*
-- 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?*
-- No answer -- Yes No
How soon are you able to move in? Please be aware that this application is for moving between September and November 2025 and we are not able to accommodate moves sooner than September, nor much later than November.*
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:*
Previous Monthly Utilities:*
Do you or your partner (if applicable) have any past due balances with landlords or utilities? If so, 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.*
Are you willing to move to a new apartment with an approved landlord in a higher-resourced community? Please be aware that this is a requirement for our program.*
-- 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
Do you have school-aged children or will your children be school-aged in the fall of 2025?*
-- No answer -- Yes No
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:
Are you (both, if applicable) willing to send your school-age child(ren) to the higher-resourced public school(s) in your new neighborhood? Please be aware that this is a requirement for our program.*
-- No answer -- Yes No This does not apply to me, as I do not have children who are school-aged.
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.*
Do you or applicant 2 pay any child support or alimony, if so, how much do you pay? *
Sources of Non-wage Income:*
Are you (and/or your partner) currently employed?*
-- No answer -- Applicant 1 is employed Applicant 2 is employed Applicant 1 and 2 are employed 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 Applicant 1 and 2 are unemployed
Current Employer:*
Current Position/Title:*
Current Employer Address*
Current Yearly Earned Income or Yearly Salary:*
Current Hourly Amount:*
Start Date:*
How many hours per week do you normally work?*
Current Yearly Earned Income or Yearly Salary from your second job:
Current Hourly Amount from your second job:
How many hours per week do you normally work at your second job?
Previous Employer Name:*
Previous Employer Address*
Previous Position/Title:*
Previous Salary Amount:*
What were you start date and end date of this job?*
Previous Employment Type:
-- No answer -- Full-Time Part-Time Temporary
Applicant 2: Current Employer
Applicant 2: Current Position / Title
Applicant 2: Current Employer Address
Applicant 2: Current Yearly Earned Income or Yearly Salary:
Applicant 2: Current Hourly Amount
Applicant 2: Start Date
Applicant 2: How many hours per week do you normally work? *
Applicant 2: Current Yearly Earned Income or Yearly Salary from your second job:
Applicant 2: What is your hourly wage from your second job?
Applicant 2: How many hours per week do you normally work at your second job?
Applicant 2: Previous Employer Name
Applicant 2: Previous Employer Address
Applicant 2: Previous Position / Title
Applicant 2: Previous Salary Amount
Applicant 2: What were you start date and end date of this job?
Applicant 2: Previous Employment Type
-- No answer -- Full Time Part Time Temporary
Are you (both, if applicable) willing to meet monthly with a life coach for 3 years?*
-- No answer -- Yes No
Are you (both, if applicable) willing to attend monthly evening programs (primarily virtually) for 3 years on Thursday evenings?*
-- No answer -- Yes No
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 Internet Search (please indicate the search engine Google, Yahoo, etc. below) 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) A person currently in the program with Families Flourish (please indicate the person's name 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
Applicant 2: 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: 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
