Application | Restoration House

Restoration House Program Application

Restoration House provides housing, mentoring, educational guidance, and life skills

training within a Christian environment for young women 18 to 24 years old. Restoration

House serves those seeking a successful transition to adulthood.

If you are . . .

a young woman*
between the ages of 18 and 24
seeking an affordable and safe place to live
motivated to set goals and work with adult mentors to help attain your goals
interested in living in a family-type home with other women your age

. . . Restoration House may be for you!

At Restoration House, we believe success includes:

✓ Educational advancement

✓ Steady employment

✓ Positive interpersonal relationships

✓ Practicing financial stewardship

✓ Stable independent living

✓ A driver’s license

✓ Being active in community service

✓ Being equipped with goals and a plan for the future

✓ Exploring a relationship with God

The application process includes five steps:

Step One: Application and Review

Step Two: Tour of Restoration House

Step Three: Interview at Restoration House

Step Four: Information Gathering (reference checks, health screen, etc.)

Step Five: Communicating a Decision

Restoration House may recommend other community resources if one or more of the

following is true if:

The young woman does not meet the admission criteria.
A woman is pregnant.
She has dependent children that live with her.
The young woman is not ready to commit to the opportunities and responsibilities available at Restoration House.
She is looking for emergency shelter only, as in the event of domestic violence or other personal crisis.
When an alternative housing option would be a better fit.

Please complete the following information to the best of your ability:

Full Name_____________________________________________________________

Birthdate ______/______/______ Phone ______-______-______

Email Address: _________________________________________

Address________________________________________________________________

City/State __________________________________Zip _________________________

Emergency Contact:

Name ____________________________________Relationship to you: _________________

Phone: ______-______-______ Email Address: ____________________________________

Describe your living situation over the last six months (circle all that apply):

in my own housing

staying with my family

staying with friends

hospital or treatment facility

homeless shelter

foster care

Why are you seeking new living arrangements?_________________________________

____________________________________________________________________________

Do you feel safe in your current living situation? Yes No Somewhat

Have you ever been in foster care? (circle one)

Yes, I am currently

Yes, but I aged out

Yes, for a time

No

If you are currently in foster care, please list name and contact information of your

guardian:

Guardian’s Name:___________________________________________________________

Phone ______-______-______ Email Address: ___________________________________

Do you have any dependents? (circle one) Yes No

If yes, do they live with you? Yes No

Do you own/have any of the following? (circle all that you have)

Driver’s license

State ID

Birth Certificate

Social Security Card

Health Insurance

Bank Account

Credit Card(s )

Vehicle

If you have a vehicle is it insured? Yes No

Education

What is the highest level of education you have completed? (circle any that apply)

Grade 9

Grade 10

Grade 11

Grade 12

High School Diploma

GED

College - 1 year

College - 2 years

College - 3 years

College - 4 years

Asoociate's Degree

Bachelor's Degree

Other _________________________________________________________________

Do your future plans include completing any of the following? (circle all that apply)

GED

High School Diploma

Vocational Training

Associate's Degree

Bachelor's Degree

Other: _________________________________________________________________

What are three things you do well? __________________________________________

__________________________________________________________________________

What goals do you have for yourself?________________________________________

__________________________________________________________________________

Do you currently support yourself? How? _____________________________________

___________________________________________________________________________

Is there anyone in your life who could help you achieve your goals? Yes No

If yes, who is this, and how will they help you achieve your goals? ________________

___________________________________________________________________________

Describe your ability to live and work with others: ______________________________

____________________________________________________________________________

What do you expect to gain from Restoration House? ____________________________

____________________________________________________________________________

How did you hear about Restoration House? ____________________________________

____________________________________________________________________________

Employment History:

Please list any employment you have had, starting with the most recent:

Employer 1

Supervisor’s Phone #

City/State

Length of Employment

Title/position

Dates of Employment

Supervisor

Reasons for Leaving

Employer 2

Supervisor’s Phone #

City/State

Length of Employment

Title/position

Dates of Employment

Supervisor

Reasons for Leaving

Employer 3

Supervisor’s Phone #

City/State

Length of Employment

Title/Position

Dates of Employment

Supervisor

Reasons for Leaving

Volunteer Experience:

Organization

Dates you volunteered

Tasks/Responsibilities

Physical and Mental Health

Please describe any learning and physical challenges you have:

______________________________________________________________________

Have you been diagnosed with any of the following: (Circle all that apply)

Major depression

Anxiety

PTSD

Bipolar Disorder

Schizophrenia

PDD/Asperger’s/Autism

Learning Disabilities

Personality Disorder

Do you have any medical conditions that would be important for us to know about? If so,

please describe them:

______________________________________________________________________

Are you pregnant? Yes No I’m not sure

Do you have any allergies? Yes No

If yes, please list:

______________________________________________________________________

Are you willing to live in non-smoking, drug-free and alcohol-free home? Yes No

Have you ever been convicted of a misdemeanor or felony? Yes No

If yes, please describe the reason you were convicted:

_________________________________________________________________________

Have you ever been arrested? Yes No

If yes, please share why you were arrested:

______________________________________________________________________

Have you ever appeared in juvenile court? Yes No

Have you ever used illegal drugs? Yes No

If yes, have you been clean and sober for at least 60 days? Yes No

Are you on probation or parole? Yes No

If yes, please answer the questions below:

Name of Probation Officer:________________________________________________

Probation Officer’s Phone Number: ________-____________-_____________

Length of probation time remaining: ________________________________________

Please list three references who can verify your willingness to live with Restoration House’s program:

Reference 1

Name

Relationship

Phone

Email

How long has he or she known you?

Reference 2

Name

Relationship

Phone

Email

How long has he or she known you?

Reference 3

Name

Relationship

Phone

Email

How long has he or she known you?

Is there anything else you’d like us to know about you? (continue on the back of this

page if needed)

___________________________________________________________________________

By signing below:

I give permission for Restoration House to contact my references, previous employers, and guardian.
I agree to being given personality, drug, and health screenings.
I give permission for Restoration House to perform a background check and request official documents to verify that my information is accurate.

Restoration House will make a decision based on this application, my interview,

recommendations of my references, and availability of space. If my statements are

found to be false at any point, or if I have demonstrated an unwillingness to work within

the expectations and terms of my admission, I may be immediately dismissed from the

Restoration House program.

I understand that Restoration House will treat my information in a confidential manner

and will not share my personal information with any other outside organizations or individuals.

____________________________________________ __________________________

Signature Date

* We realize the definition of ‘woman’ is understood diﬀerently by diﬀerent people. We

define this as a person both born and remaining biologically female; but we encourage

any young woman to apply, and we are willing to consider any applicant on a case-by-

case basis.

Restoration House Program Application

What Is Restoration House?

Restoration House of Northern Michigan