Application for Residence at Henley YMCA

Application for residence at Henley YMCA

THE DETAILS ON THIS FORM WILL BE TREATED IN THE STRICTEST OF CONFIDENCE

Please read the whole form prior to completion

First name(s): / Surname(please include any other name/s you have used or been known as)
Date completed: By Applicant / Date Received: By Office

Please note that in addition to completing this form you will need to register an application for Housing with South Oxfordshire District Council. The Council has priority nomination responsibilities for accommodation at Henley YMCA. The Council and Henley YMCA will consider whether any proposed occupier complies with the eligibility requirements. HenleyYMCA’s low-cost housing is intended to provide accommodation for persons with a housing need with have a strong local connection to the area. The Council and Henley YMCA pay particular regard to prospective occupiers having a local connection to a relevant Parish in the District of South Oxfordshire within the following priority order:

Henley but if there is no such eligible person then

1. BIX, HARPSDEN or ROTHERFIELD GREYS but if there is no such eligible person
2. Any person within the District of South Oxfordshire such a person nominated individually by the Council, or Henley YMCA as being a person to take up such accommodation.

The local Connection Clause requirement (subject to the provisions above) means that a prospective occupier shall be either:

a)A person who has continually resided in the relevant Parish for a period of not less than 5 years within the last 8 years or for such a time as to satisfy the Council of a strong local connection OR

b)A person who has a strong local connection with the relevant Parish by virtue of a close family member that is to say a parent, or child fulfilling the requirements of clause (a) above OR

c)A person who has been wholly or largely employed in the relevant parish for a period of not less than two years immediately preceding the date of nomination.

About Henley YMCA

Henley YMCA offers accommodation to Single Young People with priory being given to those with a connection to Henley/or surrounding area. Its policy is to let the accommodation available to those in the greatest housing need. The YMCA only has a limited number of flats / studios, and it cannot help everyone who applies. Therefore it recognises the importance of fair selection and allocation procedures.

Procedure for Applying For Accommodation at Henley YMCA

Applicants need to complete an application form and send it to the YMCA Housing Manager. If you are on South Oxfordshire District Council's (SODC) waiting list you can go online & bid/register an interest of living at Henley YMCA. If they are not on SODC’s waiting list, you will need to contact SODC on 01491.823325 in order toregister with them or online at

The YMCA will contact you in order to arrange an interview as and when vacancies become available. If you are invited to attend an interview you will be required to provide the following:

• Proof of Identification. Birth certificate, passport, driving licence.
• Proof of your national insurance number. This can be found on your benefits letters, your NI card, wage slips, tax letters etc
• Proof of income from benefits or employment. This can be found on your benefit awards letters, wage slips, work contract etc.

Advanced Rent.

All successful applicants must pay two week’s rent currently @ £110.30= £220.60 before they move in.

Please complete all the sections of this form. If you need any assistance in completing this form or need help in a language other than English please ask. Please let Henley YMCA know immediately of any change in your circumstances.

Personal Details

Full name (Mr/Mrs/Miss/Ms) Please include any other name/s you have been known as.
Date of birth Age
National insurance number
Present address / From
Home/mobile contact number
E-mail address
Name/Address/Telephone number of doctor
Name/Address/Contact number of next of kin (state relationship)
Name/Contactnumber in case ofemergency (if different to next of kin)
Previous addresses / From / To / Tenant/Lodger/Owner? / Name/Address of landlord / Reason for leaving
Reason for application?
Please tick below the box which best describes your reason for wanting accommodation at the YMCA
Living in overcrowded accommodation
Harassment
Health or medical reasons
Poor physical housing conditions
Breakdown of relationship with partner
Need for independence
Financial difficulties
To move out of temporary accommodation
Evicted
Discharged from long-stay institution such as prison or hospital
To move out of shared housing or a hostel
Need for higher level of support
To be near family, friends or employment
Required / asked to leave home
Refugee / asylum seeker
Homeless
Domestic violence
Other reason
Source of referral?
If someone has pointed you in our direction please tick the appropriate box
Nominated by Local Authority
Referred by Local Authority (not nominated)
Referred by statutory agency
e.g. Social Services, Probation
Referred by voluntary agency e.g. CAB
Another housing association
Direct application
South and Vale District council
Other
Are there any other circumstances you wish to be considered?
Please give details of any disabilities/health problems?
E.g. epilepsy, diabetes, asthma etc.
Do you require accommodation adapted for wheelchair access? YES/NO
Have you ever suffered with your mental health? E.g. depression, self harm,suicide attempts, sectioned etc If yes please provide details.

Under the Asylum & Immigration Act 1996 it is necessary to ask you the following

Are you a British Citizen? / Yes/No
Have you lived in the UK for the last five years? / Yes/No
If no, when did you move to the UK?
Which country did you move from?
Are you subject to any immigration rules? / Yes/No
If Yes, pleasegivedetails
If you are not a British Citizen please state your current immigration status and provide a copy of your current passport and visa.
Has a landlord ever served you with notice to say you have broken your tenancy agreement? / Yes/No
If yes, please give the reason & the name of the landlord
Have you ever had a conviction of any kind? This includes ASBO or court injunction because of anti-social behaviour? / Yes/No
If yes please give details
Do you have anyconvictions orcharges made against you (past or present)?Including schedule one sex offences and arson. / Yes/No
If yes please give details including, the name and address of your Probation Officer
Have youeverhad adrug or alcoholabuse problem? / Yes/No
If yes please give details
Do you receive medication of any kind? / Yes/No
If yes please give details
Are you pregnant? / Yes/No
If yes, what is the baby’s due date?
Have you ever been served with notice or had a court order for rent arrears? / Yes/No
If yes, please give details, including name of landlord, dates, amounts and whether you still have rent arrears.

ECONOMIC CIRCUMSTANCES

Please note that the current weekly rent & service charges total £103.61a week (subject to review on 1st April each year). All successful applicants must pay two week’s rent currently @ £103.61 = £207.22 before they move in. Thereafter rent is payable weekly in advance.

Please answer honestly. Nobody is refused consideration because their income is too high.

Economic circumstances
Please tick the box below which best describe your position 
Working full-time (16 hours or over a week)
Working part-time (less than 16 hours)
On government training scheme
Registered unemployed/ job seeker
Not seeking paid work
Full-time student
Long-term sick / disabled
Name/Address/Telephone number of Your employer or college
Do you receive any benefits? What do you receive How much? Per week?
Have you ever claimed Housing Benefit? From which local authority? When?

Support

Do you need support with the following?
Always / Sometimes / Not at all
Cleaning
Cooking
Money management/Budgeting
Taking medication
Accessing training/education
Looking for work
Applying for welfare benefits
Literacy support
Language & translation
Accessing health services
Accessing voluntary work
Are there any other areas you feel you need support with? Please state.

Ethnic Origin

The YMCA keeps records of the ethnic groups of all applicants. This information is collected to ensure that housing services are provided on an equal basis to all. The information provided will be treated in confidence and will not affect your housing application.

GENDER
Female
Male
Transgender
AGE
16-17
18-24
25 and over
(A)WHITE,
How would you describe yourself? Please tick the appropriate box
British
Irish
Other Please Specify
(BASIAN, ASIAN BRITISH
Indian
Pakistani
Bangladeshi
Other Please Specify
(C)MIXED
White & Black Caribbean
White & Black African
White & Asian
Other Please Specify
(D)BLACK, BLACK BRITSH
Caribbean
African
Other Please Specify
(E)CHINESE, OR OTHER ETHNIC GROUP
Chinese
Other Please Specify
(F)OTHER
Do you consider yourself to be a gypsy or member of another travelling community
Decline to Answer
RELIGION
No religion
Christian
Jewish
Muslim
Other
Prefer not to say
SEXUALITY
Straight
Gay/Lesbian
Bisexual
Prefer not to say
DISABILITY
No disability
Learning disability
Physical disability
Prefer not to say

Extra Information

Please use this space to provide any further information which may help us to assess your application, or if there was not enough space for your answers on this form.

Henley YMCA works in partnership with Thames Valley Police. Thames Valley Police will provide background checks on all persons applying for residence at Henley YMCA.

I certify thatI have read and understood the information provided in this application form. The statements I have made are true and I am fully aware that false statements made on this application form will result in my application being refused, my name being taken off the waiting list or accommodation being revoked.

Signed / Date

If someone else has completed this form on your behalf please complete the following:

Name of person completing the form / Relationship to you

PLEASE RETURN THIS FORM WITH TWO PASSPORTSIZE PHOTOS TO:

Lisa Grant

Templeton House

2 Lawson Road

Henley-on-Thames

Oxon

RG9 1NZ

Client Consent and Disclosure of Information

In order to help you access housing and other related support services, the YMCA will require your consent to access information about you and share this with other agencies.
Information will be shared on a “Need to Know” basis, where there is a legitimate need to know.
The YMCA will only disclose information to agencies in exceptional circumstances, for example, where you pose a serious risk to yourself or others. The intention is to ensure your safety and the safety and wellbeing of others.
The YMCA need to be able to share and get information about your case with and from a number of agencies to enable us to assist you effectively.
Please indicate here if there are any people or agencies that you specifically do not want information shared with:

I understand that the information given to the service may be shared with other organisations and agencies.

I also give the services below permission to seek and exchange information relating to my housing and support needs with the following agencies/professionals:

Please tick all that apply. It is compulsory to tick Thames Valley police and benefit/housing benefit agencies. Without this your application will not be processed.
Youth offending service / Mental health services
Probation / Hostel staff
Benefits agency / Connexions advisor
Social care / Housing associations
Housing benefit / Previous landlord
Psychiatrist / Thames Valley police
GP / Other, please specify
Print name
Signature
Date of birth

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