Client Registry Pre-Application

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Please fill out the brief screener below to determine your eligibility.

Questions marked with (*) are required.

Email *

Please choose Yes or No. *

Yes

Are you a U.S. citizen or permanent resident?

Are you currently a legal adult (at least 18 years old)?

Age group? *

18-24

25-34

35-44

45-54

55-64

65+

Are you currently incarcerated? *

Yes

If so, which facility?

Release Date?

Which state do you reside in (or if currently incarcerated, which state after your release)? *

What race/ethnicity best describes you? *

Black or African American

White

Hispanic

American Indian

Alaska Native

Native Hawaiian

Asian

Other Pacific Islander

Other:

Required

How did you hear about our program? *

Social Media

Word of Mouth

Organization Referral

Other:

If you are chosen for our program, how can we contact you or someone on your behalf? *

Send me a copy of my responses.

Submit

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