Transitional Rental Form

Aim High Resident Application

Personal Details First Name: Middle Name: Last Name: Have you ever been known by an alternate name? Yes No Date of Birth:

Contact Details Cell Phone Number: Landline Phone Number: Email Address: I consent to be contacted by Aim High via SMS, email, or phone.

Demographics Sex: Male Female Decline to respond Other: Gender Identity: Male Female Transgender Male/FTM Transgender Female/MTF Gender Queer Decline Other: Ethnicity: American Indian/Alaska Native Asian Black Hispanic Native Hawaiian White Other: Highest Education Level: No diploma GED High school Some college Associate's Bachelor's Master's+ Primary Language: Are you a veteran? Yes No If yes, what years did you serve?

Housing Questions Affiliated with a Native Corporation? Yes No How will you pay for the program? Self Someone else Insurance Assistance Other: Concerns sharing a room? Yes No Able to perform household chores? Yes No

Family & Background Marital Status: Single Married Separated Other: Fleeing domestic violence? Yes No Family reunification in process? Yes No Do you have children? Yes No

Substance Use History Drugs of choice: Meth Heroin Fentanyl THC Alcohol Other: Last drug used & when: Years of use: Use tobacco? Yes No

Health Allergies? Yes No Physical/Medical issues? Yes No Mental health diagnosis? Yes No Suicidal ideation or inpatient treatment history? Yes No Need mental health services? Yes No Currently on prescribed medication? Yes No

Treatment & Recovery Currently in a treatment program? Yes No Previous treatment programs? Yes No Sober/clean date: Do you have a sponsor? Yes No

Legal & Support Needs Open court/legal cases? Yes No Felony conviction? Yes No Need help with: Food ID Clothing Learning accommodations

Submit Application

By signing below, I affirm that all the information provided is accurate and complete.

I understand this is an initial application and further steps may be required.

Applicant Signature: ____________________________ Date: __________________ I certify that the above information is true and complete. I understand this is not a guarantee of placement.

Aim High LLC

One mind, one heart, dwell in the services of each other.

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Contact Info

(907) 3603994 | (907) 215-5321

340 North Hoyt,

Anchorage, Alaska, 99508

9:00 – 05:00 (Mon – Fri)

ea@weaimhighllc.com

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