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Preliminary Questionnaire
Please fill out this questionnaire to the best of your ability. We WILL NOT use any of this information to exclude you from participating in our programs. You may be eligible for additional services or programs based on the criteria below.
Date: *
Tip: Click on the calendar icon marked "31" and select the highlighted date.
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/
DD
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YYYY
First Name: *
Your answer
Last Name: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
How old are you? *
Your answer
Street Address: *
Number and Street Name
Your answer
Apartment Number:
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
E-mail:
Your answer
First Name of Parent or Guardian: *
Your answer
Last Name of Parent or Guardian: *
Your answer
Home Phone:
Tip: We need a phone number to contact you!
Your answer
Cell Phone:
Tip: We need a phone number to contact you!
Your answer
Alternate Phone:
Tip: We need a phone number to contact you!
Your answer
If you answer YES to any of these questions you may be eligible for a program.
This questionnaire is confidential and will be reviewed and evaluated only by a Soulciety Staff Member.
Please select the income bracket and size of your household. *
Are you or your family receiving any type of public assistance? *
(Food Stamps / TANF / GA / SSI / Disability)
Are you experiencing difficulty with your school work? *
Did you graduate high school or commplete your GED? *
Are you currently attending school? *
Are you interested in the Medical/EMT field? *
Have you dropped out of school? *
Are you a Runaway or Homeless? *
Are you Pregnant or Parenting *
Have you ever been arrested? *
Do you have an incarcerated parent? *
Have you ever had an IEP? *
Are you disabled? *
Are you currently on Probation? *
Were you formerly on Probation? *
Are you a Cal WORKS recipient? *
Are you currently in Foster Care? *
Were you formerly in Foster Care? *
Please reference any specific programming you are interested in:
Your answer
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