SECTION 1: APPLICANT INFORMATION
Full Name: __________________________
Preferred Name (if different): _________
Date of Birth: _ / / Age:
Phone Number: __________
☐ Safe to leave voicemail
☐ Text only
☐ Do NOT contact by phone
Email: __________________
☐ Safe to email
☐ Do NOT email
Current Address (or general location):
☐ Currently unhoused
☐ Shelter
☐ Staying with family/friends
☐ Other: __________________
SECTION 2: SAFETY & CONTACT PREFERENCES
Is it safe for us to contact you?
☐ Yes
☐ No
☐ Only during certain times: _______
Preferred method of contact:
☐ Phone
☐ Text
☐ Email
☐ Through a caseworker/advocate
Are you currently in immediate danger?
☐ Yes
☐ No
If yes, please call 911 or the National DV Hotline: 1-800-799-SAFE (7233)
SECTION 3: HOUSEHOLD INFORMATION
Are you applying for yourself only?
☐ Yes
☐ No
If no, please list household members who would live with you:
Name Age Relationship
Are you pregnant? ☐ Yes ☐ No ☐ Prefer not to say
SECTION 4: DOMESTIC VIOLENCE HISTORY (OPTIONAL)
You may skip any question you are not comfortable answering.
Have you experienced domestic or intimate partner violence?
☐ Yes
☐ No
☐ Prefer not to say
Type of abuse experienced (check all that apply):
☐ Physical
☐ Emotional / Psychological
☐ Financial
☐ Sexual
☐ Stalking
☐ Verbal
☐ Coercive control
Is the abuser still in your life?
☐ Yes
☐ No
☐ Unsure
Do you currently have:
☐ Protective order
☐ Open court case
☐ None
SECTION 5: HOUSING NEEDS
Why are you seeking housing through Green Light Meadows?
How soon do you need housing?
☐ Immediately
☐ Within 30 days
☐ Within 60 days
How long do you believe you will need housing support?
☐ Short-term (0–6 months)
☐ Transitional (6–24 months)
SECTION 6: INCOME & EMPLOYMENT
Current employment status:
☐ Employed full-time
☐ Employed part-time
☐ Unemployed
☐ Self-employed
☐ Student
Monthly income (approximate): $________
☐ No income
Do you receive public assistance?
☐ SNAP
☐ TANF
☐ SSI/SSDI
☐ Child support
☐ None
SECTION 7: SUPPORT SERVICES NEEDED
(Check all that apply)
☐ Safe housing
☐ Case management
☐ Counseling / mental health services
☐ Legal advocacy
☐ Employment support
☐ Financial literacy
☐ Childcare resources
☐ Transportation
☐ Life skills / independence coaching
☐ Other: __________________
SECTION 8: PET INFORMATION (IF APPLICABLE)
Do you have pets you need to keep with you?
☐ Yes
☐ No
If yes:
Type of animal(s): ______________
Number of pets: __
SECTION 9: ADDITIONAL INFORMATION
Is there anything else you would like us to know about your situation or needs?
SECTION 10: CONSENT & SIGNATURE
I certify that the information provided is true and accurate to the best of my knowledge. I understand that completing this form does not guarantee housing placement.
Applicant Signature: _______________
Date: _ / / Staff Use Only: Date Received: ___
Eligibility Status: ☐ Pending ☐ Approved ☐ Waitlisted ☐ Declined
Notes: ________________________________
🔒 Confidentiality Statement
Green Light Meadows respects your privacy. Information will not be shared without consent except as required by law or to ensure safety.
GREEN LIGHT MEADOWS
Terms of Service & Program Participation Agreement
Effective Date: _______
Green Light Meadows (“GLM,” “we,” “our,” or “the Program”) is a nonprofit organization providing transitional tiny-home housing and supportive services to survivors of domestic violence and their families. Participation in our program is voluntary and subject to the following terms.
- ELIGIBILITY & PARTICIPATION
1.1 Participation is available to individuals who meet program eligibility criteria, including but not limited to:
• Survivors of domestic or intimate partner violence
• Willingness to comply with program guidelines
• Ability to participate in case management and supportive services
1.2 Acceptance into the program does not create a landlord-tenant relationship unless otherwise stated in a separate written lease or occupancy agreement.
1.3 Program participation may be time-limited and subject to periodic review. - HOUSING & OCCUPANCY
2.1 Housing is provided as transitional, supportive housing.
2.2 Occupants agree to:
• Reside only in their assigned unit
• Not allow unauthorized individuals to stay overnight without approval
• Maintain a safe, clean, and respectful living environment
2.3 Green Light Meadows reserves the right to reassign units if necessary for safety, maintenance, or program needs. - SAFETY & COMMUNITY STANDARDS
3.1 To maintain a safe environment for all residents:
• Violence, threats, harassment, or intimidation are strictly prohibited
• Illegal drugs, weapons, and criminal activity are prohibited on premises
• Alcohol use may be restricted per program policy
3.2 Any behavior that threatens the safety of residents, staff, volunteers, or animals may result in immediate review or removal from the program. - CONFIDENTIALITY & PRIVACY
4.1 Green Light Meadows respects participant confidentiality and will not disclose personal information without consent, except:
• When required by law
• To prevent serious harm or safety risk
• For mandatory reporting obligations
4.2 Participants agree to respect the privacy and confidentiality of other residents and not share identifying information or personal stories. - CASE MANAGEMENT & SERVICES
5.1 Participants agree to:
• Engage in case management meetings
• Work toward individualized goals such as safety planning, employment, financial stability, or permanent housing
5.2 Support services may include counseling referrals, legal advocacy, employment assistance, and life-skills programming but are not guaranteed and may vary based on funding and availability. - FEES & FINANCIAL RESPONSIBILITY (IF APPLICABLE)
6.1 Some programs may include:
• Program participation fees
• Income-based contributions
• Utility or service fees
6.2 Any fees will be disclosed in writing prior to participation and will not exceed program guidelines. - PET POLICY (IF APPLICABLE)
7.1 Pets may be allowed subject to:
• Health and vaccination requirements
• Behavior and safety standards
• Capacity and housing limitations
7.2 Owners are responsible for the care, behavior, and cleanliness of their pets. - HEALTH, MENTAL HEALTH & EMERGENCIES
8.1 Green Light Meadows does not provide medical or mental health treatment.
8.2 Participants are responsible for:
• Managing their own health care
• Seeking emergency services when needed
8.3 In case of emergency, staff may contact emergency services to protect life and safety. - PROGRAM VIOLATIONS & TERMINATION
9.1 Failure to comply with these Terms or program rules may result in:
• Written warning
• Corrective action plan
• Temporary suspension
• Termination from the program
9.2 Immediate termination may occur for serious violations involving safety, violence, illegal activity, or threats.
9.3 When possible, Green Light Meadows will provide referrals or transition assistance upon program exit. - LIMITATION OF LIABILITY
10.1 Participation is voluntary. Green Light Meadows is not responsible for:
• Personal injury, loss, or damage to personal property
• Actions of other residents or third parties
10.2 Participants agree to hold Green Light Meadows harmless to the extent permitted by law. - NON-DISCRIMINATION POLICY
Green Light Meadows does not discriminate based on race, color, religion, sex, gender identity, sexual orientation, national origin, age, disability, marital status, or any other protected status under applicable law. - MODIFICATIONS TO TERMS
Green Light Meadows reserves the right to update these Terms as needed. Participants will be notified of material changes. - ACKNOWLEDGEMENT & CONSENT
By signing below, I acknowledge that:
• I have read and understand these Terms of Service
• I agree to comply with program rules
• I understand participation does not guarantee housing or services
Participant Name (Print): _______________
Signature: _______________
Date: _ / / _
⚠️ Legal Disclaimer
This document is a program participation agreement and does not constitute legal advice or a lease agreement. Green Light Meadows recommends review by legal counsel prior to final adoption.
House Rules Addendum
(Attached to and incorporated into the Terms of Service & Program Participation Agreement)
Effective Date: _______
Green Light Meadows is a shared, supportive living community created to provide safety, dignity, and stability for survivors of domestic violence. These House Rules exist to protect all residents, children, staff, volunteers, and animals.
- SAFETY & SECURITY
1.1 No Violence or Threats
Physical violence, threats, harassment, intimidation, or abusive behavior of any kind is not permitted.
1.2 Weapons Prohibited
Firearms, knives (other than standard kitchen utensils), or any weapon are not allowed on the property.
1.3 Restricted Access
• Only approved residents may live on the property.
• Visitors must be pre-approved by staff.
• Abusers, former partners, or individuals posing a safety risk are strictly prohibited.
1.4 Curfew (If Applicable)
Residents must comply with any curfew or quiet hours established for safety reasons. - VISITORS & GUESTS
2.1 Visitors
• All visitors must be approved in advance.
• Visitors must follow all House Rules.
• Staff may deny or revoke visitor privileges at any time for safety reasons.
2.2 Overnight Guests
Overnight guests are not permitted unless explicitly approved in writing by staff. - SUBSTANCES & ILLEGAL ACTIVITY
3.1 Drugs
Illegal drugs, drug paraphernalia, and misuse of prescription medication are prohibited.
3.2 Alcohol
Alcohol use may be restricted or prohibited depending on program guidelines and safety considerations.
3.3 Illegal Activity
Criminal activity of any kind on or near the property is prohibited. - RESPECTFUL COMMUNITY STANDARDS
4.1 Respect & Conduct
Residents must:
• Treat others with respect and dignity
• Avoid gossip, harassment, or intimidation
• Respect cultural, personal, and emotional boundaries
4.2 Noise & Quiet Hours
Quiet hours must be observed to support rest, healing, and children’s needs. - CHILD SAFETY & SUPERVISION
5.1 Parents or guardians are responsible for:
• Supervising children at all times
• Ensuring children follow community rules
• Preventing disruptive or unsafe behavior
5.2 Physical discipline or abuse of children is not permitted. - PROPERTY CARE & CLEANLINESS
6.1 Unit Care
Residents are responsible for:
• Keeping their unit clean and sanitary
• Reporting maintenance issues promptly
• Preventing damage beyond normal wear
6.2 Common Areas
Shared spaces must be left clean and usable for others.
6.3 Prohibited Alterations
Residents may not alter units, install fixtures, or make repairs without written approval. - PET POLICY (IF APPLICABLE)
7.1 Pets must:
• Be approved in advance
• Be properly vaccinated and licensed
• Be under control at all times
7.2 Owners are responsible for:
• Cleaning up after pets
• Preventing noise or aggressive behavior
Pets that pose a safety risk may not be allowed to remain on the property. - SMOKING & VAPING
8.1 Smoking and vaping are prohibited:
• Inside all housing units
• Inside common buildings
8.2 Designated outdoor smoking areas may be provided if allowed by policy. - COMPLIANCE WITH CASE MANAGEMENT
9.1 Residents must:
• Attend scheduled case management meetings
• Participate in goal planning and program requirements
Failure to engage may result in program review. - RULE VIOLATIONS & CONSEQUENCES
10.1 Violations may result in:
• Verbal or written warning
• Corrective action plan
• Temporary suspension of privileges
• Termination from the program
10.2 Serious safety violations may result in immediate removal.
10.3 When possible, Green Light Meadows will offer referrals or transition planning upon exit. - RIGHT TO MODIFY RULES
Green Light Meadows reserves the right to modify House Rules as necessary to maintain safety and program integrity. Residents will be notified of changes. - ACKNOWLEDGEMENT
I understand that these House Rules are designed to protect the safety and wellbeing of everyone in the Green Light Meadows community. I agree to follow them as a condition of participation.
Resident Name (Print): _______________
Signature: _______________
Date: _ / / _
🔒 Confidentiality Reminder
Residents must not share identifying information or personal stories of other residents inside or outside the program.
⚖️ Legal Disclaimer
This House Rules Addendum does not create a landlord-tenant relationship and is not a lease. It is subject to review under Georgia law.
GREEN LIGHT MEADOWS
Progressive Discipline Policy
Effective Date: _______
Green Light Meadows (“GLM”) is committed to maintaining a safe, respectful, and supportive community while recognizing that residents may be healing from trauma. This policy outlines a fair, consistent, and compassionate process for addressing rule violations and supporting residents in meeting program expectations.
- PURPOSE
The purpose of this policy is to:
• Promote safety and accountability
• Encourage corrective behavior rather than punishment
• Provide clear expectations and consequences
• Ensure consistent and equitable responses to rule violations - GUIDING PRINCIPLES
• Safety First: Immediate action may be taken when safety is at risk.
• Trauma-Informed: Responses will consider trauma history and stressors.
• Consistency & Fairness: Policies are applied uniformly.
• Due Process: Residents are informed of concerns and given opportunity to respond. - TYPES OF VIOLATIONS
3.1 Minor Violations
Examples include:
• Missed appointments without notice
• Noise complaints
• Failure to maintain cleanliness
• Minor rule misunderstandings
3.2 Moderate Violations
Examples include:
• Repeated minor violations
• Unauthorized visitors
• Noncompliance with case management
• Disrespectful behavior
3.3 Major Violations
Examples include:
• Violence or threats
• Weapons on property
• Illegal drugs or criminal activity
• Serious safety violations
• Harassment, stalking, or intimidation - DISCIPLINARY STEPS
Step 1: Verbal Warning
• Staff discusses the issue privately with the resident
• Expectations are clarified
• Support or resources may be offered
• Documentation is placed in the resident file
Step 2: Written Warning
• Written notice outlining:
• Policy violated
• Required corrective action
• Timeline for improvement
• Resident may submit a written response
• Additional support services may be offered
Step 3: Corrective Action Plan
• Developed collaboratively with the resident
• Includes:
• Specific behavior changes
• Support services
• Follow-up timeline
• Failure to comply may escalate consequences
Step 4: Probation
• Temporary status with increased monitoring
• Duration determined by program leadership
• Conditions clearly outlined in writing
Step 5: Termination from Program
• Used only when other steps fail or safety is compromised
• Written notice provided when possible
• Referrals and transition support offered when appropriate
- IMMEDIATE ACTION (SAFETY EXCEPTIONS)
Green Light Meadows reserves the right to bypass progressive steps and take immediate action, including suspension or termination, when there is:
• Imminent risk to safety
• Violence or threats
• Illegal activity
• Severe policy violations
Emergency services may be contacted when necessary. - RESIDENT RIGHTS
Residents have the right to:
• Be informed of alleged violations
• Share their perspective
• Request reasonable accommodations
• Receive written documentation - APPEAL PROCESS
7.1 Residents may submit a written appeal within 5 business days of a disciplinary action.
7.2 Appeals will be reviewed by:
☐ Program Director
☐ Executive Director
☐ Review Committee
7.3 A written decision will be provided within 10 business days. - DOCUMENTATION & CONFIDENTIALITY
• All disciplinary actions are documented
• Records are kept confidential and secure
• Information is shared only on a need-to-know basis - NON-RETALIATION
Green Light Meadows prohibits retaliation against any resident for reporting concerns, participating in investigations, or exercising their rights. - POLICY REVIEW & MODIFICATION
This policy may be updated to meet legal, safety, or program requirements. Residents will be notified of significant changes. - ACKNOWLEDGEMENT
I acknowledge that I have received and understand the Progressive Discipline Policy and agree to comply as part of my participation in Green Light Meadows.
Resident Name (Print): _______________
Signature: _______________
Date: _ / / _