Application for Journey to Adult Success
Interested in living at JAS House? Please fill out the form below. All answers and information will be kept confidential. We do not discriminate based on religion, race or creed, sexual orientation, gender, age, national origin, or disability.

Questions? Please call (920) 609-5071.
Name
Email address
Phone number
Date of birth
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/
DD
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Gender
Clear selection
Current address
Are you aging out of foster care? Or have you ever been in foster care?
Are you currently homeless?
Clear selection
Have you ever experienced homelessness?
Clear selection
Current school and date of graduation
Have you completed the following?
Are you currently enrolled in post-secondary education? If yes, please list the institution and start date.
Do you have a job? If yes, please list your employer's name, address, and phone number, as well as your position, wage, supervisor's name, and length of employment.
Have you received any legal charges that would prevent you from gaining employment? If yes, please list the charges and dates.
Please list the name of an emergency contact, as well as their phone number and relationship to you.
Please list any medications you're currently taking.
Please list any allergies.
Have you ever received outpatient counseling for alcohol or drug use? If yes, please list the dates and locations.
Please list any other medical conditions.
Do you smoke cigarettes?
Clear selection
Please list three personal references, as well as their phone numbers and relationships to you.
Do you identify with a specific cultural community? If yes, which one?
Do you identify with a specific religious or spiritual community? If yes, which one?
Why should we consider you as an applicant for this program?
What do you hope to gain from this experience?
Is there anything else you'd like us to know about you?
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