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HOME
DONATE
OUR STORIES
OUR TEAM
CONTACT US
Registration
GIVE US A CALL
Program Registration
First Name
Middle Name
Last Name
Date of Birth
Address
Apt #
City
State
Zip Code
Email:
Phone:
Emergency Contact Information
Middle Name
Last Name
Address
Apt #
City
State
Zip Code
Email:
Phone Number
Will you have a safe / stable place to live on release date?
Yes
No
Beginning date of most recent incarceration:
Facility Name (jail / prison)
Scheduled Release Date
Number of felony charges
Number of misdemeanor charges
Are you currently on probation or parole?
Yes
No
If yes, please provide the name of the Officer you are assigned to. Also include your terms and concerns:
Do you have any pending court cases?
Yes
No
If yes, please explain:
Do you have any medical conditions we need to be aware of (including allergies)?
Do you have any mental health conditions we need to be aware of?
Do you have a documented disability / on SSDI?
Yes
No
Do you have Medical / Dental insurance?
Yes
No
If yes, please specify all assistance that apply (Medicaid, Kid Care, Medicare, SSDI):
Are you receiving, or living in a household that receives government assistance (including food stamps, social security, or cash assistance?
Yes
No
If yes, please specify all assistance that apply
Do you have a driver’s license?
Yes
No
Do you have a 2nd form of Identification?
Yes
No
Please specify type
State ID Card
Social Security Card
Birth Certificate
Passport
Do you have access to reliable transportation?
Yes
No
Are you currently employed?
Yes
No
If yes, where are you working?
If not working, are you currently seeking work?
Yes
No
Please provide details such as schedule, barriers to employment, are you getting interviews, waiting for a hire date
What is your highest level of education (check below)?
High School Diploma or GED
College or Other Degrees
Trade of Technical Training
Are your financial obligations under control?
Yes
No
Please provide types of financial obligations and if on-time, have made a payment plan, or are behind in each obligation (child support court fees, fines)
What is your biggest challenge currently?
Tell us about your support system (family members, spouse, children, pastors/church, counselors, friends, etc.)?
What are your goals for the next three months?
What are your major goals for the next two years?
What are your major goals for the next two years?
What do you want to accomplish with Reverse The Door?
What is your main education goal?
What is your main career goal?
Do you have any goals for your personal relationships (such as improving communications, spending more time together, making reparations, etc.)?
I understand that my participation in the Reverse the Door program is completely voluntary.
Yes
No
Notes & Action
Thank you for contacting us.
We will get back to you as soon as possible.
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Main Office
4001 SE Commerce Avenue
Stuart, FL 34997
Contact
Phone: 772-485-1279
Email:
[email protected]
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