Arukah House Application
This application must be done by the person apply for residence in the Arukah program. Family and friends are not allowed to fill application for client. Please answer all questions honestly and to the best of your ability. If you are a convicted sex offender Arukah is not able to house you.
Email address *
Name *
First and last name
Your answer
Email
Your answer
Phone number
Your answer
Which home location are you interested in applying for? *
Address/City/State/Zip
Your answer
Sex *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Height *
Your answer
Weight *
Your answer
Race *
Your answer
Driver's License *
DL#
Your answer
Are you willing to commit up to one year to an intense discipleship training program? *
Are you willing to spend the first 30 days with no distractions to help focus on moving forward and develop healthy habits? (telephone calls, visitors, or letters) If you are coming out of Prison we will allow you to connect with family that is safe. *
Do you have any pending legal matters that would take you away from the Arukah House? *
If you are on probation or parole you must have a letter from your officer stating the conditions of your parole officer or supervising officer, upon entering the Arukah House.
Your answer
Do you have any pending medical conditions that would take you away from the Arukah House or hinder you from participating in the job vocational training? *
Have you been diagnosed with any mental illnesses? *
Do you have any personal matters that would take you away from the Arukah House? *
Do you have a vehicle or other mode of transportation? *
Marital Status (Check One) *
Emergency Contact (Name, Relationship, Phone, Email, Address)
Your answer
Do you own a vehicle? *
Have you ever been arrested? *
If Yes please explain all times you have been arrested?
Your answer
Probation or Parole Officer's: (Name and Phone)
Your answer
Are you currently incarcerated? *
If Yes, What CDCR Facility are you at?
Your answer
Are you court ordered here? *
If yes, who is notified when you terminate the program? (Name, contact info)
Your answer
Are you a convicted felon? *
If yes, please state all convictions and dates of prison sentences.
Your answer
Have you had any misdemeanors in the past 5 years? *
If yes, please state all misdemeanors and dates
Your answer
Have you ever had any gang affiliation? *
If yes, which gang?
Your answer
Year that you joined the gang?
MM
/
DD
/
YYYY
Are you still affiliated with gang?
Have you publicly denounced gang membership?
Year you got out of gang?
MM
/
DD
/
YYYY
Do you have any outstanding warrants or traffic violations? *
If yes, please explain.
Your answer
Do you have health insurance? *
If yes, which provider?
Your answer
What is your Doctors name, contact information?
Your answer
Do you have any current health problems? *
If yes, what are they?
Your answer
Are you currently taking any prescriptions? *
If yes, what are they?
Your answer
Do you have any diagnosed mental illness? *
If yes, what diagnoses have you received?
Your answer
Are you currently on any medication for mental illness? *
If yes, what are you taking?
Your answer
Do you have regular Doctor or Dentist visits? *
If yes, who are your providers?
Your answer
Where have you worked in past years? Please give name of company, position, and year of employment. *
Your answer
What types of jobs are you qualified for? *
Your answer
Do you have children *
How many and what are their ages?
Your answer
Are you paying child support? *
If yes, how much per month?
Your answer
List all financial responsibilities you currently have? (Include cars, credit cards, and any other bills you have) *
Your answer
Total debt you have? *
Your answer
What brings you to the Arukah House? *
Your answer
Please list all current and past drug use with date of last use. *
Your answer
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