Application Information Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLast (if behaviors housing Date of Birth (MM/DD/YYYY) *Phone Number *Email *Current Residential Address *Room Compatibility Preference *Male roommates onlyFemale roommates onlyOpen to co-ed sharingPrefer private room (if available)—Independent Living Eligibility—Are you able to perform daily activities independently (bathing, dressing, toileting, feeding)? *YesNoDo you manage your own medications (if applicable)? *YesNoDo you require 24-hour supervision or medical care? *YesNoAre you able to live cooperatively in a shared housing environment? *YesNo—Community Living & Safety—Are you currently experiencing behaviors that may impact shared housing (aggression, severe conflict, property damage)? *YesNoDo you require home health, nursing, or caregiver services? *Yes (must be self-arranged)NoSmoking Status *Non-smokerSmoker (must follow smoke-free property rules)—Monthly Income Source—Monthly Income SourceEmploymentSSI / SSDIVA BenefitsPensionOtherApproximate Monthly Income *Enter your estimated total monthly incomeAre you able to pay rent monthly and on time? *YesNo—Emergency Contact—Emergency Contact Name *Relationship *Emergency Contact Phone *— Acknowledgment —Please confirm the following:I understand that Tranquil Oasis Living is an independent living residence and does not provide medical care, personal care, or supervision.I certify that the information provided is accurate.I understand that submission does not guarantee placement.Submit
