SWITCHBACK APPLICATION FORM

Print off an application form here and email completed form to alyssa@cyruscentre.com or fill out an electronic form below.

The Switchback Supportive Housing for Youth & Young Adults

Application Form

Page 1 of 3

1. Applicant

2. What city/town do you currently stay in?

3. How can we reach you?

Is there anyone we can leave a message with in order to contact you?

1st Contact or Organization:

* Authorized Contact?

2nd Contact or Organization:

* Authorized Contact?

3rd Contact or Organization:

* Authorized Contact?

Authorized Contact Permission Information:

*By saying yes under Authorized Contact, you are confirming that you have the contact’s permission to provide their information and you are giving permission for the Switchback to exchange information with that contact in order to maintain and update your application. Authorized Contacts can be added or removed by contacting the Switchback.

IMPORTANT: If we are unable to contact you, we will move to the next applicant.

4. What are your sources of income?

LIst all sources and amounts. (if on income assistance, specify if employable, PWD or PPMB)

1st Income Source

2nd Income Source

3rd Income Source

5. Current Living Situation

Please select the one option that best describes your current living situation:

If you chose Other, please specify your current living situation

If you chose Yes above, what is the date when you must leave your current living situation?

If Yes, which one and why?

6. Health and Wellness

Please describe in as much detail as you're willing to share.

7. Justice System Involvement

Justice system involvement does not in itself impact the outcome of your application.

If Yes, what is the name and contact information of the officer you are required to report to?

DECLARATION AND CONSENT

Please indicate your accceptance of this Declaration and Consent form by filling in your name above.
PLEASE NOTE: YOU CANNOT SUBMIT THIS FORM UNLESS YOU AGREE TO ALl THE CONDITONS UNDER "I Declare" and "I Understand"