Find Roommates

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ROOMMATE i-MATCH

PAGE 1. ROOMMATE MATCHING INFORMATION.

Please answer the following questions to help potential roommates determine if you may be a good match. (Note: if there is someone else filling out this survey, or another primary point of contact, we will ask for that later.)

(*) Indicates that the specified field is REQUIRED for you to submit the form.

You must have JavaScript enabled in your browser. If it is off, there will be a message in orange at the top of the page.

Please use the scrollbar to review this agreement and then check that you agree. By checking "I agree" below, I am agreeing that:

1. The individual seeking a roommate is at least 18 years old.
2. The person filling out this survey is at least 18 years old.
3. Information submitted is at my own discretion and of my own free will.
4. If I am not the individual seeking a roommate, I have received consent from the individual to submit the survey on his or her behalf.
5. The information submitted is truthful and accurate.
6. I understand that the information submitted is maintained by the Arc of Northern Virginia (the Arc). Some or all information from this survey may be shared with potential roommate matches. 
7. This survey does not include a background check and does not verify the validity of the information provided.
8. Roommate matches are not guaranteed.
9. This survey is only for the purposes of helping individuals connect with others looking for a roommate.
10. It is the responsibility of me and/or my representatives to follow up on possible roommate matches and to take proper precautions to ensure safety.
11. The Arc of Northern Virginia is not liable for any communications, meetings, or other interactions between individuals who are connected as possible roommate matches.
12.  I understand that this roommate match does not provide access to support services or rental assistance.

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Agreement with terms of service:(*)

I agree You must agree with the Terms of Service to submit this form.

A. Information about the PERSON SEEKING A ROOMMATE:

First and Last Name:(*)

Enter the name of the person seeking the roommate. Use alphabetic characters.

Year of Birth(*)

Provide a 4-digit YEAR of birth (e.g., 1992). The person must be over 18.

Residence:(*)

Select one of the choices provided.

Gender:(*)

Male

Female

Transgender Male / Transman /FTM

Transgender Female / Transwoman / MTF

Does not identify as male, female, or transgender

Please select one of the choices.

Are you a smoker?(*)

SmokerNon-Smoker Please select one of the choices.

Pet preference:(*)

Any pets OKDogs onlyCats onlyNo dogs or cats (small reptile, fish, hamster OK)I cannot live with pets Please select one of the choices.

Describe any pets you are bringing:

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B. Information about the ROOMMATE(s) you are looking for:

Prefer(*)

Male

Female

Transgender Male / Transman / FTM

Transgender Female / Transwoman / MTF

Does not identify as male, female, or transgender

No preference

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Prefer(*)

SmokerNon-smokerNo preference Please select one of the choices.

PAGE 2. HOUSING INFORMATION.

Please enter information helping us to match homes and people. (If you are looking for a home, click B1 to answer questions about your housing preferences. If you have a home to share, click B2 to answer questions about your home.)

Looking for a home or already have one to share?

B1. Looking for a place to share with a roommate or roommates

B2. Have a place already and am looking for someone to move in with me

Chose one or the other.

B2. Information about the home or apartment YOU HAVE TO SHARE.

Street (not unit#):(*)

Please include the street address only, not the unit number.

City:(*)

Please enter a city name, alpha characters only.

This property has:

Fewer than 10 steps inside and/or outside

More than 10 steps inside and/or outside

No steps inside and/or outside

An elevator

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Pets:

Pets are not allowed

No pets currently, but allowed

A pet or pets live within the unit (please describe below)

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Type of pet(s)

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The property is:

Within walking distance of public transportation

Not within walking distance of public transportation

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What is the estimated maximum monthly rent AND utilities that someone must pay or contribute to live with you? Please describe below.

Monthly amount:(*)

Please enter a number. Do not include the decimal point or dollar sign.

B1. Please provide information about the PLACE YOU WOULD LIKE to live.

If you want to live in Fairfax County, VA, please check this map to determine which Region you are interested in, then select that region from the pull-down choices below. The pull-down list is not exhaustive and is meant for reference to the general area. (The map will open in a new browser window.)

First choice:(*)

Please choose where you would most like to live (your first choice).

Second choice:(*)

Please indicate your second choice or pick "No second choice".

I need the unit to have:

Wheelchair accessibilityModifications for hearing impairmentNo stepsMinimum Steps (less than 10)Modifications for visual impairmentOther Invalid Input

Accessibility Needs:

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I need:

Public transportation within walking distance

No preference to be near public transportation

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What is the maximum monthly amount you can afford for your portion of the rent AND utilities?

Maximum $ amount for rent and utilities:(*)

Please enter numbers only. Do not include a decimal point or dollar sign.

Are you and another person (or persons) looking for someone to live with?

PAGE 3. Points of Contact for follow-up

Please provide contact information for the person who will be contacted if there is a potential roommate match. (This may or may not be the person seeking a roommate.)

Relationship of the point of contact to the individual seeking a roommate?(*)

Self - I am the person seeking a roommateParentSiblingOther family memberFriendPaid SupportOther (please specify) Please select one of the choices.

Relationship:

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Name of POC:(*)

Please provide the first and last name of the person to be contacted.

Email:(*)

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Phone:(*)

Please provide the phone number of the point of contact. Use the same format as: 703-555-1212.

Please use the box below to include other pertinent information or explanations, or to ask questions. Do not include any personally identifiable information (PII) or protected health information (PHI). Thank you!

Other pertinent information, or comments:

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Please check the "I am not a robot" box and follow its instructions.
Then after you have passed its tests, click the Submit button.

(*)

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