THP Youth Applicant FORM 2
TO BE COMPLETE BY YOUTH APPLYING FOR SIERRA QUEST'S TRANSITION PROGRAM - Part 2

This is FORM 2 of our Transitional Housing Program plus Foster Care (THP+FC) youth application. If you have not completed FORM 1, please click this link to complete it now.  https://docs.google.com/forms/d/e/1FAIpQLScvBsnwdR7GwHohXJXMsO0uDfcd3UlEsHT3MBau_XqKgg1U-A/viewform

This FORM asks more detailed information and you should set aside at least 30 minutes to complete it at one time. You will have the ability to edit the information after you submit it.  You will also get instruction at the end on how to get a link to edit your responses at a later date.

If so, you will need to complete FORM 2 before final determination is done.  If any question is unclear, feel free to call (209) 966-7095 or email us at sqthp@squest.org and we will get back to you as soon as possible.

ALL YOUR INFORMATION WILL BE KEEP CONFIDENTIAL AND HELD IN OUR A HIPAA SECURE DATABASE. No information will be released without your expressed permission.
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First Name *
Last Name *
Birthdate *
Email
(if you don’t currently have an email, please ask your placement casework to assist you in setting up a gmail account)
Current Phone
(or contact number)
Mobile Phone
Do you currently have a working mobile/cell phone? If so, list number and carrier (ATT, MetroPC, etc.)
Emergency Contact
In case of an emergency, who is your emergency contact(s)?  Include name(s), relationship and phone number(s)
Emergency Info
What information you are permitting us to share with your emergency contact(s)? Example: health status, location, contact information, criminal charges, bail amount, etc.
Current Income
List any current sources of income?
Scheduled Funds
Are you scheduled to receive SSI or trust funds at age 18 or in the near future?  If so, what do you expect to do with the funds?
Checking Acct
Do you have current Checking Account? If yes, which Bank?
Saving Acct
Do you have current Saving Account? , If yes, which Bank?
Medi-Cal Card
Will you have your Medi-Cal Card with you when you enter THP?  If not, what is your plan to get it?
Fines/Restitution Due
Do you have any fines or restitution due? If so, amount and to whom
Other Debt
Do you have any other debt?  If so, amount and to whom
Check Items you have *
List your plan below if get anything that is missing
Yes
No
If no, do you have a plan to get it? (share below)
Not Applicable
Birth Certificate
California ID
California Driver's License or Permit
Medi-Cal Card
Computer, Laptop or Tablet
Social Security Card
If you're a non-citizen, do you have a Green Card or Maturica Card
If you are missing any above, what is your plan to get them?
List any other official photo ID?
What is the name on your Birth Certificate?
Have you had any name changes?
If so, please explain
SSI
Are you receiving SSI?
Vehicle
Do you own a Vehicle? Is it properly registered and do you have required insurance for it?If so, list Make, Model, License Plate #, plus Insurance Policy Carrier and Proof of Insurance #. (NOTE: driving without license, registration or proper insurance, may be ground for termination from THP)
Parenting
Are you a parent or currently expecting the birth of your child? If so, please tell us about your parenting needs. How many children do you have?  What are the children's current living situation?  Are you the custodial parent? Is there a child support order?  Is there a shared parenting arrangement? If so, who is the other parent and what is your current parenting and/or visit arrangement?
Juvenile Record
If you have been found to have committed a crime as a juvenile, do you know the status of sealing your juvenile record?
FAFSA, CADA
Have you completed FAFSA or California Dream Act Application (CADA)? If so, date of completion
Chafee, Pell Grant
Have you completed a Chafee or Pell Grant Application? If so, date of completion
Scholarship / Grants / Loans
Have you completed any college scholarship, education grant or educational loan applications? If so, please list
ESSAY QUESTIONS
THP Success
Share your understanding of THP+FC programs and what you think you would need to do to be a successful participant
Why SQTP?
What do you know about Sierra Quest’s THP+FC program and why are interested in participating in this program?
Feeling about past
What is your attitude about past activities and/or past associations or friends that may be negative for your future?
Support Team
Do you have anyone who you consider to be a part of a positive support team for you? If so, who are they and how can they be supportive?
Spiritual Practice
Do you have a spiritual commitment or practice that is important to you? Do you have a spiritual advisor or fellowship/group that are connect to? How will these contribute to your success and support?
Prep for Success
Based on your past experiences, what areas of your life do you feel have prepared you to be successful?
Managing Risks
Based on your past experiences, what areas of your life do you feel you need to manage to ensure you can be successful? (Example: To be successful, I need to continue in my recovery from drugs and alcohol, stay on my meds, watch who I hang out with, avoid old friends or associates, avoid unhealthy relationships, not allow myself to get lazy, etc.)
By 21 (B21)
By the time you turn 21, what do you hope you have accomplished?
Career
Do you have an idea what type of career (beyond just a job) you would like to pursue?
By 30
What goals would you like to reach by age 30?
Free time
How do you usually spend your leisure or free time? How do you plan to keep from becoming bored or boring?
Self-Improvement
Do you have any activities or practice you regularly do for self-improvement? If so, please list them and how often you do them
Exploration
While in THP, what are new areas of recreation, leisure, social activities, self-improvement or adventures you want to explore or get involved with?
Self Guidelines
For Sierra Quest, we want your apartment to be a clean, safe and drama-free space for you. This means no gang activities, no drugs and no live-in partners. How do you plan to keep your apartment a sanctuary for your success? Please list the rules you plan to set for yourself and guests at your apartment?
AB12 Eligibility
For THP+FC and SILP, you must maintain AB12 eligibility through employment (80 hours per month), school (HS or ½ time college) or have a medical exception. How do you plan to maintain your AB12 eligibility? (Note: If you are not working or attending school, you will be required to do 20 hours a week of “Removing Barrier” activities)
Plan B
If you enter into SQTHP, and realize that this is not the program for you, or find yourself at risk of termination,  what currently is your alternative living arrangement (Plan B)?
Referrences
Please list at least two people, other than your Social Worker/Probation Office, who can provide a reference for you. Please indicate how best to contact them. They can provide us an online reference by clicking on this following link.  By listing these references, you are authorizing us to disclose your name and your interest in our program. We will not disclose any other information.  Online Reference Link:
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