Date of application:
To be completed by the applicant
Please complete this form as accurately as possible. Answer all of the questions except for the
section marked for office use only. Your application form can be sent to us by:
• Hand delivery to the reception of Nottinghamshire YMCA, 4 Shakespeare Street, NG1 4FG
• Scan and email to [email protected]
• Complete a form online at nottsymca.org
If you need help filling out your form, please come to the main hostel and a member of staff will be
happy to help.
To support your application, please provide 2 forms of ID. This could include a passport, driving
licence or birth certificate.
First name:
Date of birth:
Place of birth:
Contact number:
Age:
Surname:
Email address:
NI number:
Gender: Male
|
Female
1. Reason for application
Are you homeless? Yes
No
Fleeing domestic abuse
Evicted
Financial difficulties
Family, friends or employment
Poor housing conditions
Racial harassment
Other harassment
Needing higher support housing
Required to leave home
Moved on to low support housing
Need for independence
Over crowded accommodation
Physical health problems
Refugee or asylum seeker leaving NASS accommodation*
Partner relationship breakdown
Re-housed from hospital
Re-housed from other institution
Re-housed from temporary accommodation
Rough sleeper
Shared housing or hostel
Moved out of temporary accommodation
Prison leaver
Other, please specify:
*Please provide a copy of your Home Office paperwork confirming your immigration status.
Have you been to Housing Aid or Housing Solutions to register as homeless?
continued....
Yes
No
Page 1
2. Previous addresses
Please provide us 5 years of previous address. Use a separate sheet if required.
Previous address one
Previous address two
Address:
Address:
Type i.e. sofa surfing:
Type i.e. sofa surfing:
Date from: Date to:
Date from: Reason for leaving:
Date to:
Reason for leaving:
A location connection is defined by
“Having lived inside of the Nottinghamshire County boundary for 6 out of the last 12 months
or
having lived inside of the Nottinghamshire County boundary for 3 out of the last 5 years
or
having immediate family living within the Nottinghamshire County boundary whom you have a consistent
relationship with such as parents, siblings and children ages 18 and over
or
you are a refugee who has had their refugee decision and status whilst residing inside the Nottinghamshire
County boundary”
After reading this statement, do you consider yourself to have a local connection? Yes
No
3. Ethnicity
White
English / Welsh / Scottish /
Northern Irish / British Other Mixed / multiple ethnic
background, please specify:
African
Caribbean
Irish Other Black / African / Caribbean back
ground, please specify:
Gypsy or Irish Traveller
Other White background, please specify:
Black / African / Caribbean / Black British
Asian / Asian British
Indian
Pakistani
Bangladeshi
Mixed / multiple ethnic groups White and Black Caribbean
Other ethnic group
Chinese
Arab
Other Asian background, please specify:
Other ethnic group, please specify:
White and Black African
White and Asian
continued....
Page 2
3a. Are you an EEA national? Yes
No
If yes, please contact us to complete an EEA declaration form.
4. Referral source
Direct application
Housing association
Health service of GP
Local authority
Probation service of prison
Statutory agency
Social services
Voluntary agency
Other, please specify:
5. Support Needs
Please select your support needs from the options below.
Please tick all that apply.
Alcohol related problems
Drug related problems
Frail elderly
Mental health problems
Anxiety and/or depression
Physical long term illness
Financial difficulties
Finding work / education
Domestic abuse
Leaving care
Hoarding
5a. Are you pregnant? Yes
Learning difficulties, please specify:
Non English speaker
What is your first spoken language?
Other, please specify:
No
If yes, what stage of your pregnancy are you at?
continued....
Page 3
5b. Support
Are you involved in any activity with any support agencies?
Name of worker
Address
Contact Number
Probation
Youth support
Drug services
Alcohol services
Mental health services
Outreach services
Floating support
Other
6. Risk
Are you experiencing any problems in the following areas / or at risk of any of the following?
Risk
no risk
low
medium
high
Mental health
Violence
Domestic violence
Alcohol abuse
Substance abuse
Sexual abuse
Crime related issues
Long term illness
Disabilities
Gambling
Other, please specify:
6a. Do you have any convictions for any of the following?
Arson
Weapons
Criminal damage
Sex offenses
Drink / drug related
Violence / harassment
Burglary
Offenses against minors or
the vulnerable
Please provide details:
continued....
Page 4
6b. Are there any known incidents of physical violence? Yes
If yes, what relationship did you have to this person?
No
What was the severity of the incidents?
Minor injury
Serious injury
Death
What is the occurrence of this? (1 = once to 5 = frequently)
1
6c. Do you have any other criminal convictions?
Yes
2
3
4
5
No
If yes, please give details:
Conviction i.e Burglary,
weapon possession.
Sentence i.e fined,
community service
or prison
Are you on:
Year of
conviction
6d. Do you have any spent or pending convictions?
Bail
Yes
Parole Licence
If served, what is
the length of your
sentence?
No
If yes, please give details:
7. Current Situation
Main source of income
Employment Support Allowance (ESA)
Disability Living Allowance (DLA)
Personal Independence Payment (PIP)
Income Support (IS)
Job Seekers Allowance CB (JC)
Job Seekers Allowance IB (JI)
Working Full Time
Working Part Time
continued....
Universal Credit (UC)
Apprenticeship (AP)
Student Grant
Pension
None
If none, have you made a claim
for benefits? Yes
No
Other, please specify:
If yes, what date did
you make a claim for?
Page 5
7a. Signing on
To accompany your application, please provide proof of income with your completed
application. This may be a bank statement, benefits letter or the Proof of Income form to be
signed by DWP.
What is your sign on day?
What date is your next benefits payment due on?
Date:
7b. Sanctioning
Are you currently sanctioned?
Yes
No
If yes, please give details:
What stage of sanctioning are you on?
1st
2nd
3rd
What is the duration of your sanction?
8. Next of kin contact information / person of contact
Mr
Title:
Mrs
Miss
Ms
Address:
First name:
Surname:
Relationship to applicant:
Contact number:
Email address:
continued....
Page 6
9. References
Please provide two references to support your application
Reference one
Reference two
Name:
Name:
Address:
Address:
Relationship to applicant:
Relationship to applicant:
Contact number:
Contact number:
Email address:
Email address:
Signature and declaration
All information stored by Nottinghamshire YMCA is done so in accordance with the Data Protection Act 1998.
By signing below, you agree that:
• All information you have given in your application is true
• If your application is accepted and Nottinghamshire YMCA finds you have given false information you may be
asked to leave, or your application may be withdrawn from the application process
• You information will be stored in Nottinghamshire YMCA’s paper-based and electronic systems
• Nottinghamshire YMCA may exchange your information with external agencies to support your application for
stay/potential stay
Signed (Applicant)
Name (Applicant)
Date
For office use only
Criteria checking
Has the applicant supplied 2 forms of identification that has also been checked by the YMCA?
2. Does the applicant have a local connection?
3. Is the applicant an EEA national?
Yes
Yes
No
Yes
No
5. Has the applicant provided information about their support needs?
Yes
continued....
Yes
No
No
7a. Has a Proof of Income form been signed?
Is the application missing information?
No
No
3a. If yes, has an EEA declaration been submitted?
5a. Is the applicant pregnant?
Yes
Yes
Yes
No
No
Page 7
If yes, what information is required?
Sign
Name
Date
Part 2 – Interviewing
To be completed by the YMCA
Interview booked by
Date and time interview booked for
Interview conducted by
Sign
Name
Date
Application / interview notes
Please continue on separate sheets and attach if necessary.
continued....
Page 8
All information stored by Nottinghamshire YMCA is done so in accordance with the Data Protection Act 1998.
By signing below, you agree that:
• All information you have given in your interview is true
• I f your application is accepted and Nottinghamshire YMCA finds you have given false information you may be
asked to leave, or your application may be withdrawn from the application process
• You information will be stored in Nottinghamshire YMCA’s paper-based and electronic systems
•N
ottinghamshire YMCA may exchange your information with external agencies to support your application for
stay/potential stay
Signed (staff )
Signed (applicant)
Name (staff )
Name (applicant)
Date
Date
Part 3 – Outcomes
Has this applicant been accepted?
Yes
No
If no, please give details why:
Sign
Name
Date
Next steps
Has a Key Worker been assigned?
Has an Outcome star appointment been made?
Yes
Yes
No
If yes, who is the Key Worker?
No
If yes, please answer the following:
Time
Date
Has a resident induction been booked?
Yes
No
Date
Management
Sign
Name
Date
Page 9