20 May 2012

Our aim is not to just provide young people with somewhere to live, but to give them something to live for.

The information provided and additional rent account data in relation to any applicant or resident will be stored on a computer data retrieval system. "This organisation is committed to upholding the 8 data protection principals of good computer practice" Date Protection Act 1984. Reg. No: Z1499481

Please complete all sections of this form.

Personal Details
First Name
Middle Names
Surname
Date of Birth
N.I. Number
Marital Status
Telephone
Mobile
Current Address
House Name/No.
Street/Road
Town/City
County
Post Code
Next of Kin
Name
Relationship to you
House Name/No.
Street/Road
Town/City
County
Post Code
Telephone
Mobile
Reasons For Application
Evicted Harassment Health or medical reasons
Poor physical housing condition Need for support To be near family, friends or employment
Breakdown of relationship Need for independence In B&B or temporary accommodation
Move out of shared or hostel Financial difficulties Living in overcrowded accommodation
Discharged from long stay institution Required to leave home Other reasons

In providing accommodation High Wycombe YMCA operates a policy of Equal Opportunities. We aim to provide a good standard of accommodation for single young people in the greatest housing need regardless of gender, race, faith, disability or sexual orientation. To ensure that this policy is carried out we monitor those who apply and those who are offered accommodation to make sure that all applicants are treated strictly on the basis of their need, and that no group of applicants is considered less favourably than others.

To help us in assessing your application please give details below of your current situation including any other information you wish to be taken into consideration.

Please click in those boxes below which best describe your current circumstances:

A. Client Group
AIDS/HIV Degenerative & debilitating illness Leaving penal establishment
Alcohol related problems Mental health related problems Young person leaving care
Drug related problems Leaving other supported housing Refugees/asylum seeker
Learning difficulties Women at risk of domestic violence Young person at risk
Physical disability Single homeless in need of support Other
B. Current Accommodation
Approved probation/bail hostel Living with family Living with friends
Children's home/foster care Local authority tenant Private tenant
Hospital Residential care home Hostel/shared housing
Housing Association Tenant Other temporary accommodation Owning or buying
Prison Self-contained supported housing tenant Other
C. Source of Referral
Wycombe District Council Social Services/Leaving Care Team Youth Offending Team
Probation Citizen’s Advice Local Paper
Direct Application Supported Housing Association Friend
Tea Warehouse Y.E.S. Other
D. Economic Circumstances
Working full-time (Over 16 hours) Working part-time (16 hours or less) Registered Unemployed
Full-time student On Government Training Scheme Incapacity or other benefits
How long have you lived at your present Address?
What is your total pay after deductions £
Does any of your money come from Benefits?
Will you quality for Housing benefit if you are offered accommodation at the YMCA?
Health
Asthmatic Diabetic Depression/Mental Health
Disability Hearing impaired Visually impaired
Epileptic None Other
If other, please give details
Details of regular medication
Doctor's Details
Name
House Name/No.
Street/Road
Town/City
County
Post Code
Telephone Number
Additional Information
When do you need the Accommodation?
Do you require accommodation for a wheelchair user?
Do you have any Criminal Convictions/Court Orders/Police Involvement etc?
If yes, please give details
Do you or have you had a history of problems relating to Drugs/Alcohol/Gambling?
If yes, please give details
Do you have any friends or relations living at this YMCA?
Have you lived at High Wycombe YMCA before?
If you are currently renting accommodation, please provide details of your landlord
Name
House Name/No.
Street/Road
Town/City
County
Post Code
Telephone Number
References

Please give the name, address and telephone number of two people (not relatives) that you have asked to act as a reference as to your personal character (employer, priest, teacher, social worker, probation officer or support worker).

First Reference
Name
House Name/No.
Street/Road
Town/City
County
Post Code
Telephone Number
Relationship to you
Second Reference
Name
House Name/No.
Street/Road
Town/City
County
Post Code
Telephone Number
Relationship to you
Please give details of your reasons for applying to High Wycombe YMCA, and how you think you will benefit from this accommodation.
Please give details of any other circumstances you wish to be considered in support of your application.

I declare that to the best of my knowledge the information that I have provided is true and complete. Failure to declare information which may later come to light will invalidate this application and may result in the termination of any licence/tenancy issued.

I will inform High Wycombe YMCA should my circumstances change.
I accept Date: 20/05/12