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Register here
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Indicates required field
Applicant Name
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First
Last
Phone
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Date
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PLEASE PROVIDE THE FOLLOWING:
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DD214 and VA Medical Card
State ID, or Driver’s License
Social Security Card
Income Verification (pay stubs, award letters for pension, SSI/SSDI, VRAP, etc.)
Non-cash Income Verification (food stamps)
Current lease, eviction notice, or other documentation to explain needs or concerns.
If you have family members living with you, we will need the above items for them as well.
Names and ages of family members residing with you.
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Age
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Last address
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Do we have your permission to contact them?
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YES
NO
If NO, please explain why, in detail.
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Choose Any
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I understand this is a 90-day program.
A cleaning deposit is required of $100.00. If you do not have this, a payment arrangement is to be reached with Walking Down Ranch (WDR) management and placed in your file.
I understand that by submitting this application, I grant permission for WDR to perform a background and/or credit check to determine my eligibility for transitional housing.
SERVICES PROVIDED:
You will be provided with private accommodation. Our cabins are completely furnished, clean and comfortable. (a $100 deposit is required)
There is a community kitchen area in the main office. Breakfast and dinner are served Monday – Friday. The menu is posted ahead of time, and you may sign up at the 9:00 AM daily meeting.
Food is provided in the unit when you move in. If you have an income and/or food assistance you are expected to provide what you can for yourself. For those with no income, grocery lists are collected on Wednesdays and delivered on Friday for the weekend. If your list is not returned, you will be responsible for your food over the weekend.
A television and DVD player will be provided, if available. Movies are available in the thrift store and Veteran Outreach Center (VOC).
A computer is available in the VOC for classes, job applications, and employment research.
Transportation to Doctor visits and VA appointments may be available with a 24-hour notice.
We can assist with VA, DES, and Social Security appointments.
AA and NA meetings are held on the property weekly, and counselors are available on request. Participation in a church service is recommended.
SERVICES NOT PROVIDED:
Medical services
Personal non-emergency transportation (There is a bus route nearby)
Maid, cleaning, and laundry services
Cable T V
Landline Phone Service
ACCEPTANCE:
Guest Name
*
First
Last
I have read and agree with this list of rules and services. Per Arizona Statute A.R.S. #33-1308, I understand that I am a guest at Veterans Village and Walking Down Ranch, Inc.
Guest Name
*
First
Last
I Also agree that in the event I am asked to vacate, I will do so in a peaceful manner without causing a disturbance to other guests or doing harm or damage to property or persons. Any violation of the rules will be cause for immediate eviction.
Guest Signature
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Date
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Manager Signature
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Date
*
Why are you requesting residence at WDR Veteran Community housing?
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What are your short and long-term goals?
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How long do you estimate it will take to reach your goal and what is your first step?
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How do you think WDR can best assist you with reaching your goals?
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What is your biggest fear entering this program?
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Please state in your own words what you expect of yourself, as a member of this program?
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Current Financial Snapshot
Monthly Income Sources:
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Total Income:
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Monthly Expenses:
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Total Expenses:
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Estimated Savings Per Month
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Projected Monthly Expenses:
Housing
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Utilities
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Transportation
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Food
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Pets
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Other
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Can any of my expenses be reduced? If so, how?
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Can my income be increased? If so, how?
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I swear all information I reveal to the staff of WDR, my caseworker and legal authorities will be the truth. Covered by confidentiality I will reveal all information pertinent to my recovery, success, and well-being. Any concealed information, untruthfulness or unreported change in my situation will be just cause for WDR to request I leave the facility immediately without any damage to property, disturbance to other guests or harm to individuals trying to help me. I acknowledge I am solely responsible for my actions and success or failure.
I am accepting a hand up not a handout and am required to be responsible for my future.
Veteran Name
*
First
Last
Veteran Signature:
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RULES
I acknowledge that I am requesting services from the Walking Down Ranch, Inc., under the supportive services for Veterans. To receive these services, I make the following agreements.
Veteran Name
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First
Last
Date
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Case Manager:
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First
Last
Time:
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Please initial each directive.
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1. I understand this is a 90-day program and I will be evaluated to assess my progress every 10 days or more as WDR management deems necessary.
2. I will participate in a collaborative effort to determine a successful plan which will enable me to secure permanent housing and self-sustainability. I understand I will be reevaluated often, and my housing unit may be inspected at any time.
3. I will fully disclose any barriers to obtaining and/or maintaining permanent housing to my WDR management immediately, so they can provide me with the most comprehensive and successful services and referrals.
. All information regarding my eligibility (including but not limited to: Veteran status, family, medical history, and income) will be truthful and accurate. I will provide a copy of my DD214 and proof of registration with DES and Veteran facilities.
5. I understand that financial planning with WDR management is required for my success.
6. I will keep my appointments and follow through with referrals as agreed upon with my case manager. I will notify my case manager immediately if my circumstances change in any way that affects my ability to comply with the program (job loss, relapse, change in family structure or health issues etc.).
7. I understand that information necessary for coordination of my success will be shared with the appropriate staff and will be protected by confidentiality.
8. I will put forth the effort to succeed and understand that while my case manager will assist me, I am ultimately responsible for my wellbeing and success.
As my goal is to prosper and succeed, I will register with the Department of Economic Security and Veteran Assistant Representative for job referral information.
10. I will continue to be engaged with the Veteran Medical Services to ensure my physical and mental wellbeing, as well as the Veteran Service Representative for additional assistance.
11. I will be respectful to all those who are helping me, and those who live in this community. I understand it is at their discretion that I am being assisted.
12. Any vulgarity, disruptiveness, drug or alcohol abuse will terminate my ability to reside on these premises.
13. Visitors are allowed on the property from 9am-10pm only. No overnight visitors are allowed. All visitors are to park outside of the gate. Guests are responsible for all actions of their visitors. Violations of the facility rules may result in your immediate eviction.
14. Any disturbance, conflict, arrest, and violation of these rules will result in immediate eviction.
Veteran Name:
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First
Last
[object Object]
Date
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Caseworker Signature:
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First
Last
[object Object]
Date
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Guest Agreement
As a guest of Veterans Village, I understand that in lieu of rent, adults residing in my household at Walking Down Ranch are required to perform 20 hours of work per week, in a position they are capable of performing. I understand that any medical restrictions will be considered by staff in their placement of work responsibilities.
It is my responsibility to report to 9:00 AM meetings daily for instruction and record and turn in my work hours on my time sheet weekly.
I understand that I am obligated to perform these duties as a guest, for the services I am receiving. If I do not perform as agreed, I will be considered in violation of this agreement, which may result in my immediate eviction.
Guest Name (Print)
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First
Last
Guest Signature
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Board Member Name:
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First
Last
Board Member Signature:
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PERSONAL INFORMATION:
Name
*
First
Last
Social Security Number:
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Date of Birth:
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Gender:
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Male
Female
EMEGENCY CONTACT INFORMATION:
Emergency Phone Contact Number and information
Name
*
First
Last
Relationship
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Name
*
First
Last
Relationship
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
MAILING ADDRESS:
Street or P.O. Box
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City
*
State
*
Zip
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If Physical address is different from Mailing address:
Street
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City
*
State
*
Zip
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Cell Phone:
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Alternative Phone:
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Email:
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Marital Status:
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Single
Married
Separated
Unmarried Partner
Divorced
Widowed
If Divorced, please indicate Year
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If Widowed, please indicate Year
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ETHICITY: OPTIONAL, this is only relevant for grant purposes
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Native American
Alaskan Native
Asian
Pacific Black
Latino
Black/African American
Caucasian
Hispanic
Other
DRIVERS LICENSE OR ARIZONA ID
Date Issued:
*
DL Number:
*
Expiration Date:
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Is your license valid?
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YES
NO
If not, why:
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Do you own a vehicle?
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YES
NO
If yes, make and model:
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Is your vehicle insured?
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YES
NO
If yes, by whom:
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Do you have any outstanding tickets or warrants?
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NO
YES
If yes, explain:
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CRIMINAL HISTORY:
DO YOU HAVE ANY CRIMINAL CONVICTIONS?
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NO
YES
Misdemeanor:
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YES
NO
Felony:
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YES
NO
Child Abuse:
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YES
NO
Domestic Violence:
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YES
NO
Do you have any other, non-criminal, legal barriers?
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NO
YES
If yes, please explain:
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MILITARY HISTORY:
Branch of Service:
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Army
Army Reserves
Marines
Navy
Merchant Marines
Coast Guard
National Guard
Air Force
Service Dates:
from
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To
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Rank when entered
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Rank at Discharge
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Nickname
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Disabled:
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NO
YES
If YES, percentage
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Discharge:
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Honorable
General
Medical
Other than Honorable
Other than Honorable, please explain why:
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ERA
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WWII
Korea
Vietnam
Desert Storm
Afghanistan
Iraq
Other
EDUCATION:
Highest Graded
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High School Name
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GED or High School Diploma
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Vocational/ technical Degree
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In
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College AA
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In
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College BA
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In
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Post Grad/MA/PHD
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In
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Military Education and Training
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Were you exposed to "Agent Orange"?
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NO
YES
If your answer is YES:
Where?
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When?
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How?
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From
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Until
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Have you filed a medical claim?
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Yes
No
If so, when?
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Employment
Are you currently employed?
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YES
NO
If yes, complete the following:
Company:
*
Length of Employment:
*
Pay Rate:
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Nature of Work:
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Please document your last three jobs:
Company:
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Dates of Employment:
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Pay Rate:
*
Nature of Work:
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Reason for Leaving:
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Company:
*
Dates of Employment:
*
Pay Rate:
*
Nature of Work:
*
Reason forLeaving:
*
Company:
*
Dates of Employment:
*
Pay Rate:
*
Nature of Work:
*
Reason for Leaving:
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Choose If you are unemployed, what do you feel are barriers to your employment? Please check all that apply.
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Reading / Literacy Skills
Under Employment
No Driver’s License or ID
Older Worker
Parole
Lack of Stable Housing
Unresolved Legal Issues
Felony Conviction
Misdemeanor Conviction
Insufficient Education or Credentials
Excessive Debt / Bankruptcy
Back Child Support
Probation
Lack of Transportation
Lack of Childcare
Physical limitations
Poor Work History
Registered Sex Offender
MEDICATIONS:
Were any of the following medications used by you
prior
to military service?
Opiates:
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Codeine
Oxycontin
Morphine
Vicodin
Methadone
Fentanyl
Benzodiazepines:
*
Xanax
Klonopin
Valium
Ativan
Mood Stabilizers/Antipsychotics:
*
Valproic Acid
Lithium
Gabapentin
Risperdal
Depakote
Zyprexa
Lamictal
Seroquel
Tegretol
Were any of the above medications used by you
during
military service?
Opiates:
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Codeine
Oxycontin
Morphine
Vicodin
Methadone
Fentanyl
Benzodiazepines:
*
Xanax
Klonopin
Valium
Ativan
Mood Stabilizers/Antipsychotics:
*
Valproic Acid
Lithium
Gabapentin
Risperdal
Depakote
Zyprexa
Lamictal
Seroquel
Tegretol
Were any of these medications used by you after military service?
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YES
NO
If yes, which medications?
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Do you take any medications currently?
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YES
NO
If yes, which medications?
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Physical and Mental Health (Last 12 Months)
How would you say your physical health is, in general?
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Excellent
Very Good
Good
Fair
Poor
Explain:
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How would you say your mental health is, in general?
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Excellent
Very Good
Good
Fair
Poor
Explain:
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Does your health limit your ability to complete any of the following?
Light activities, bending, lifting.
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YES
NO
Moderate activities, carrying groceries, exercising, or sports.
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YES
NO
Heavy activities, moving furniture.
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YES
NO
Do you have any physical disabilities or limitations that should be considered when assigning work duties?
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YES
NO
Explain:
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In the past 12 month:
Were you bothered by any recurring health issues?
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YES
NO
If so, how many days per month?
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Did your recurring health issues keep you from responsibilities at work, school, home?
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YES
NO
Have you had significant problems with headaches, faintness, dizziness, tingling, numbness, sweating, hot or cold spells?
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YES
NO
Have you gone to the emergency room?
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YES
NO
If so, how many times?
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Thought about killing or hurting someone else?
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YES
NO
Thought about committing suicide?
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YES
NO
Purposely damaged or destroyed property?
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YES
NO
Have you taken money, property or anything that didn’t belong to you?
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YES
NO
Sold, distributed, or helped make illegal drugs?
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YES
NO
Have you been arrested or booked and charged with a crime?
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YES
NO
Please add any further comments about yourself you would like us to consider in the decision of your approval for residence, about this questionnaire, or your past.
*
THANK YOU FOR YOUR COOPERATION FOR FILLING OUT THIS APPLICATION. ALL INFORMATION IS STRICTLY CONFIDENTAL AND WILL BE PROTECTED BY THE PRIVACY LAWS OF THIS STATE.
CONFIDENTIAL RIGHTS AND LIABILITIES
Both Federal and State Laws protect a Guests right to privacy. These laws state that clinical information, including written records, must be kept confidential unless the Guest gives written consent to the contrary.
However, this confidentiality is not absolute. Information will be released without a Guest’s consent in the following situations:
1. When the Guest presents an immediate danger to themselves, or others.
2. When a court subpoenas their record.
3. When staff suspects child or elder abuse.
4. Generally, information is released to identify person(s) and/ or agency(s) for a specific purpose(s) and is time sensitive.
I have read the above information, and I understand my rights to, and limits of confidentiality.
Guest Name (Print)
*
First
Last
Guest Signature
*
WDR Intake Name (Print)
*
First
Last
WDR Intake Signature
*
Dated:
*
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The Annual Sock Hop 2024
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