IL-1
09/09
Please initial if
you
meet this definition
1. Name:
______________________________________________________________
_
2. Phone 1: ( Phone
2:
(
3. Contact Person and Phone number (if other than consumer):
_______________________
_
4.
Address:
____
~-----------------------------------------------------_
(Street)
(City)
(State)
(County) (Zip Code)
5. Date
of
Birth:
_____________
_
Email Address:
___________________________
_
6. Social Security Number:
_________________
_
( ) Male ( ) Female
7. Do you wish to receive our quarterly newsletter? ( ) Yes
()
No ( ) Electronically ( ) Mail
a. Hispanic or Latino:
b.
American Indian
or
Alaska Native:
c.
Black or African American:
d.
Asian:
e. Native Hawaiian
or
Other
Pacific Islander:
f. White:
9. Language: (Primarily Spoken)
()
English ) Spanish ( ) Other:
_______________
_
10. Marital Status: ( ) Never Married ( ) Married ) Divorced ( ) Widowed ( )Separated
11. Living Situation: (Check only one)
( ) NurSing Home
()
ParenUGuardian
Home
( ) Assistive Living
) Family/Friends
( ) Group Home ( ) Transitional Housing
()
Own HOllse
) Homeless
( ) Rent to Own ( ) Renting House/Apartment
()
Other
____________
_
12. Are you presently employed? ( ) Yes ( ) No $
____
_
( ) Part Time ( ) Full Time ( ) Supported Employment ( ) Transition Student
If
you are presently working, where are you employed?
___________________________
_
13. Are you presently retired? ( ) Yes ( ) No
( ) with Company Benefits
()
with Social Security Benefits $
_____
_
14. Are presently unemployed? ( ) Yes ( ) No
( ) Seeking Employment ( ) Not Seeking Employment ( ) Never Worked
( ) Receiving Unemployment $
______
_
15. Have you been
in
the military? ( ) Yes ( ) No
16. Are you eligible for veteran's benefits? ( ) Yes ( ) No Veterans Number
_______________
_
© Tri-County Independent Living Center 2011
This document contains both information and form fields. To read information, use the
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INDEPENDENT LIVING PROGRAM
APPLICATION
Independent
living
Services and Centers for Independent
living
For purpose
of
title VII, the term "individual with a significant disability" means an individual with a
severe physical or mental impairment whose ability to function independently
in
the family
or
community or whose ability to obtain, maintain, or advance on employment is substantially limited and
for whom the delivery
of
independent living services will improve the ability to function, continue
functioning, or more towards functioning independently
in
the family or community or to continue
in
employment, respectively.
8. Race: (Individuals may select more than one category)
