program application i. indentifying informtion · 2019-08-02 · program application please answer...
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1
PROGRAM APPLICATION
Please answer all questions completely. All information is confidential.
I. INDENTIFYING INFORMTION
Date of Application
Maiden Name
Name (First, MI, Last)
Any other last names you have gone by
Current Address
City State County Zip
E-mail address
Phone Number
Cell Number
DOB Age
FL Driver’s License #
Work Number
Ethnicity SS Number
Are you a citizen of the United States? (CHECK ONE) YES NO
If no, are you authorized to work in the U.S.? YES NO
Person referring you to The New Beginnings
Relationship to referring person Phone
2
Briefly describe your religious beliefs
If referred by a church, please list the name of referring church
List previous addresses beginning with the most recent
Address Dates Reason for Moving
If The New Beginnings were unable to reach you at above phone, is there an alternate
number in which you can be reached?
Please list all social media account Names:
Facebook: _____________________________________
Twitter: ________________________________________
Instagram: _____________________________________
Snapchat: ______________________________________
II. MARITAL STATUS
(CHEK ONE) Married Divorced Never Married
(Ex)Husband’s Name: Age:
Describe your current relationship with your (ex)husband (include character, job,
education, car etc.):
3
List all previous marriages
Name Date of Marriage Date of Divorce
(Ex) Boyfriend’s name Age
Describe your current relationship with your boyfriend (include character, job, education,
car etc.)
III. CHILDREN
CHECK ONE WHERE YOU SEE “YES” AND “NO”.
Child’s Name Sex DOB Age Grade Father’s name
Are you currently pregnant? (CHECK ONE) YES NO Due Date:
4
Do you have legal custody of each of your children? YES NO If not, explain:
Do you or your children have any existing illnesses?
Please list all medications that you or your children currently take.
Have you or any of your children ever:
• Been prescribed an anti-depressant, anti-anxiety or any other psychotropic
medication? YES NO If yes, name of medicine and dosage:
• Attempted suicide or had any kind of suicidal thoughts? YES NO If so, please
explain:
• Had previous serious illness? YES NO
• Been hospitalized in past 12 months? YES NO
Do you or your children have any history of fire setting, aggressive behavior or cruelty to
animals? YES NO If yes explain:
5
Have you ever had any involvement with Dept. of Child & Families (DCF)?YES NO
If yes, please list date(s) and circumstances leading to the referrals.
Describe your relationship with your children:
Describe your children’s relationship with their father:
6
Describe your children’s relationship with their grandparents:
IV. APPLICANT’S FAMILY INFORMATION
Your Father’s Name Contact Number(s)
Address
Your Mother’s Name Contact Number(s)
Address
List names of your siblings, address, phone numbers & age:
7
Describe your relationship with your parents:
Other Supportive Relatives
Relationship Name Describe Relationship
V. PERSONAL INFORMATION
CHECK ONE WHERE YOU SEE “YES” AND “NO”.
Have you ever used drugs? YES NO List type and how often:
Do you smoke? YES NO If yes, how much?
Do you drink? YES NO If yes, how often?
Are you currently on probation?YES NO If yes, explain:
Have you ever had a psychological evaluation? YES No Date completed:
Who conducted the psychological evaluation?
9
Have you and/or your children been in a psychiatric hospital? YES NO
If yes, list dates and reason for hospitalization.
Have you ever lived in a shelter? YES NO
If yes, when and where:
Have you ever been in counseling? YES NO Dates:
Have you ever been physically abused? YES NO By whom?
Briefly explain:
What are your special interests and abilities?
Explain your circumstances:
10
What do you want to accomplish by enrolling in The New Beginnings Program?
VI. EDUCATION
CHECK ONE WHERE YOU SEE “YES” AND “NO”.
Last grade in school completed: Do you have a High School diploma or GED?YES NO
Have you taken any college entrance exams?YES NO
Are you currently enrolled in College? YES NO If yes, where:
Describe any other job training you have completed:
What are your EDUCATIONAL goals?
11
Have you received any loans for education at any time? YES NO If yes, explain:
Are you defaulting on any loan or credit card debt? YES NO If yes, explain on last page
VII. WORK HISTORY List employment, beginning with most recent
Business name
Address
Supervisor
Hourly Wage
Position
Dates Employed
Monthly Pay
Reason for Leaving
Business name
Address
Supervisor Dates Employed
Hourly Wage Monthly Pay
Position Reason for Leaving
12
Business name
Address
Supervisor
Hourly Wage
Position
Dates Employed
Monthly Pay
Reason for Leaving
What are your employment goals?
VIII. REFERENCES
Employer Reference
Name Phone Number
Business name and address
Family Member Reference:
Name Phone Number
Address Relationship
13
Friend Reference:
Name Phone Number
Address
Professional (Teacher, pastor, doctor, Sunday school teacher etc.):
Name Phone Number
Address
IX. TRANSPORTATION
CHECK ONE WHERE YOU SEE “YES” AND “NO”.
Do you have a car? qYES qNO
Model
License plate # Value
Running Condition
Do you have car insurance? YES NO Do you have a valid driver’s license? YES NO
Personal vehicles are not needed within the first 18 months of the TNB program.
Do you have medical insurance? YES NO If yes, with whom:
Do you receive Medicaid Benefits? YES NO Do you receive WIC assistance? YES NO
Make Year
Do you receive social security benefits? YES NO If yes, what is the amount?
14
Do you receive food stamps? YES NO Do you receive TANF? YES NO
Do you receive child support payments? YES NO If yes, what is the amount?
X. CRIMINAL HISTORY
Have you ever been convicted of a felony?
Have you been accused of any crimes involving children?
Have you been convicted of a misdemeanor?
If yes, explain:
Do you have a current indictment against you?
Are there current charges pending against you?
The information contained in this application is correct to the best of my knowledge. I
understand that the completion of application does not guarantee placement with The New
Beginnings.
SIGNATURE DATE
15
MONTHLY INCOME AND EXPENSES
INCOME
WAGES/JOB
CHILD SUPPORT
SOCIAL SECURITY
SSI
TANF
FOOD STAMPS
OTHER
TOTAL INCOME
EXPENSES
MEDICAL EXPENSES
HOUSING
Rent
Taxes
Electric
Gas
Water
Telephone
Maintenance
Other
INSURANCE
Auto payments
Life
Health
Other
DEBTS
Source Total Owed
Monthly Payment
Monthly Due Date
Amount Past Due
18
TOGETHER PROGRAM ~ Parent Needs Survey
Listed below are some needs commonly expressed by parents. Please put a check next to each item
if you need help in that area.
Childcare needs
Budgeting Skills
Finding
Medical/dental
resources for
myself/my child
Parenting skills
Information about
community
resources
Discipline
Techniques
Job skills
Resume writing
Increasing my self-
esteem
My relationship
with others
Counseling needs
for myself/my child
Information about
nutrition, feeding,
or buying food
Handling children’s
jealousy with their
brother or sister
Dealing with
problems with
relatives
Bible Studies
Help with education
or GED
Being more
assertive
Anger management
Time management
skills
Career counseling
Help with
addictions: (Circle
all that apply)
+Alcohol
+Drugs
+Smoking
+Pornography
Organizational skills
Housekeeping skills
Any other needs
(list)_________________
NAME DATE
19
Please explain why you should get a spot in the program…..
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