SWITCHBACK APPLICATION FORMPrint 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 AdultsApplication FormPage 1 of 31. ApplicantName*Please selectMrMrsMsMissDrPrefixFirstLastDate of Birth*mm/dd/yyyy or use calendar widgetGender*2. What city/town do you currently stay in?City/Town*How long have you been here?*Current Address3. How can we reach you?Your Phone Number*Your Email AddressFacebook NameIs there anyone we can leave a message with in order to contact you?1st Contact or Organization:Contact or Organizaton NamePhone NumberEmail AddressContacts relationship to youAuthorized Contact* Authorized Contact?YesNo2nd Contact or Organization:Contact or Organization NamePhone NumberEmail AddressContacts relationship to you* Authorized Contact?YesNo3rd Contact or Organization:Contact or Organization NamePhone NumberEmail AddressContacts relationship to you* Authorized Contact?YesNoAuthorized 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.Next4. What are your sources of income?On Income AssistanceYAGEmploymentNo IncomeLIst all sources and amounts. (if on income assistance, specify if employable, PWD or PPMB)1st Income SourceNameAmount (Monthly)2nd Income SourceNameAmount (Monthly)3rd Income SourceNameAmount (Monthly)5. Current Living SituationPlease select the one option that best describes your current living situation:Staying with friends or relativesTreatment facility or detoxSleeping outsideHospitalAt an emergency shelterPrivate market - Single room occupancyCorrectional facilityPrivate market - own rental or suiteOtherIf you chose Other, please specify your current living situationHow long have you been living like this?*Is there a deadline to leave your current living situation?*YesNoDateIf you chose Yes above, what is the date when you must leave your current living situation?Why do you need or want to move?*What is something you wish you could do, but can't because of your living situation?*Have you ever stayed in a shelter?*YesNoIf Yes, which one(s)?If no, why not?Is there a shelter you prefer?YesNoIf Yes, which one and why?BackNext6. Health and WellnessPlease describe in as much detail as you're willing to share.Mental Health:Physical Health:Substance Use:No health conditions7. Justice System InvolvementJustice system involvement does not in itself impact the outcome of your application.Are you currently on probation or bail?*YesNoIf Yes, what is the name and contact information of the officer you are required to report to?Do you have any outstanding charges?*YesNoIs there anything else you would like us to know?DECLARATION AND CONSENTI declare:*This is my application to be considered for supportive housing and all the information in it is true, correct and complete.I understand:*That the Switchback program is a program agreement and not a tenancy agreement. There are certain expectations for the residents to maintain their placement in the program.It is my responsibility to contact the Switchback at least once every month for my file to remain active.If there is a unit available and I cannot be contacted, the Switchback will move on to the next applicatant.If I am being considered for an available unit, I will be invited to the Switchback for an initial interview. At that time, I will be asked to provide additional information to find out if the program is the right fit for me.If I wish to withdraw this Declaration and Consent, I may do so at any time by contacting the Switchback; however, withdrawal will result in my no longer being considered for placement.Applicant Name*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"Date*BackSendThis field should be left blank
