Shepherd’s LightHouse

5930 SE Robinson Rd

Belleview, Florida 34420

352-347-6575

Fax 352-347-1775

 Pre Screen Application

 

Date: ____________

 

*Please attach a current photo when faxing this application*

 

Potential Resident Name: _______________________________   Age  ________

 

SS# ____-___-____   DOB: __/__/____    Contact Phone #: _____-____-______

 

Current Address: _________________________________

 

Employment Status: Employed____   Unemployed ____  Where Employed___________________

 

Ever been in Shelter before? Yes____  No___ When/ Where/How long? ______________________

 

Explain any Medical Conditions you or your children have 

received treatment for in the past or currently?

___________________________________________________________

 

___________________________________________________________

 

___________________________________________________________ 

 

List Current Medications for you and your child or children. 

 

___________________________________________

 

___________________________________________

 

Drivers License # & State   _______________________________

 

License Status ________________

 

Florida ID Yes___________   No_______________

 

Have you ever been arrested Yes _____ No___  

 

If yes are you currently on probation___________

 

When will your probation terminate _______ 

 

What for? _________________________When/Where ____________________________________

Children Information:

 

1. Name ___________________________________M_____   F______

 

    Age ______ DOB ___/___/____

  

2. Name __________________________________ M ______F______

  

    Age:_______ DOB ___/___/____

 

Are your children currently enrolled in school or Daycare?

 

If Yes  Which School or DayCare _______________________

 

How often do they attend? _________________

 

Are you currently pregnant? Yes_________ No________

 

Do you have legal custody? Yes___ No___ Then Who _______________________

 

Do you have other children not living with you? Yes ________

 

Then who do they live with __________________________________

 

What role does the father play in the child’s life?________________________

 

 Are you married? Yes ____ No____  Do you have family in the area?  Yes ____ No_____

 

If Yes What role do they play in your life? ___________________________________________

 

Are you Now or have you ever been a victim of Domestic Violence? Yes ___ No _____

 

If yes give a brief description of the situation.

 

_____________________________________________

 

_____________________________________________

 

_____________________________________________

 

 

Have you ever used drugs or alcohol? Yes____ No____

 

If yes list drug of choice and when last used_________________________________

 

Educational background: High School Diploma ____ GED _____ Some College _______

 

 

Do you have your own transportation? Yes_____ No____

If yes you will be required to show proof of current car insurance.

 

List those that you can depend upon to help transport you and your children.

 

_____________________________________

 

_____________________________________

 

 

List four things that you want to accomplish by being in this program:

 

1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
4. ________________________________________________

 

 

The following items are required prior to interview:

• SS Cards
• Birth Certificates for yourself and children
• Current Florida DL or ID
• Current shot records on the children
• Proof of all income including food stamps, cash assistance, wages,                                                                                                    child support or any other means of income.
• Resume  

 

 

 

Referred by:

 

Name__________________________ Phone (352)____________________

                                        

 

• Please fax to 352-347-1775 upon completing this form.
• Please attach a current photo of your self and your children with this