Transitional Housing & Empowerment Program
Jacob’s Home Application Packet
Where the home is the classroom for life
Complete every section. Return by email to contact@jacobs-home.com or hand your packet to a staff member. Applicants must be ages 18–23.
Applicant Information
Full name
Date of birth / Age
Phone
Pronouns
Current Living Situation
Circle one: Foster placement · Residential facility · Shelter · With friends or family · Unhoused · Own lease · Other
Describe your current housing situation
Education Status
Circle one: In high school · Diploma · Working on GED · GED earned · College · Trade school · Not enrolled
School, program, or education goals
Employment Status
Circle one: Full-time · Part-time · Looking for work · Job training · Not working
Employer, hours, and work history
Independent Living Assessment
For each skill, circle: 1 = Need to learn · 2 = Learning · 3 = Confident
- Budgeting & money management1 2 3
- Banking & credit1 2 3
- Cooking & meal planning1 2 3
- Cleaning & home care1 2 3
- Laundry1 2 3
- Transportation1 2 3
- Time management1 2 3
- Job search & keeping a job1 2 3
- School or training enrollment1 2 3
- Managing appointments & documents1 2 3
Personal Goals
What do you want to accomplish in the next year?
Emergency Contact Information
Name
Relationship
Phone