Filling the Gap Information Sheet
To help inspire others with similar backgrounds as ourselves to excel beyond what society and life circumstances have set to be the norm.
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Email *
Email Address *
First Name *
Last Name *
Best Phone Number *
Please share your social media handle
Purpose of Connection *
Do you have access to stable technology? *
Are you filling this form out for someone else that is currently incarcerated or detained? If so, please state your Full Name and Relationship to the person.
Your contact number & email of person completing
Charge(s)/conviction(s), include date(s) of sentencing and release(s), ODRC # and location of incarceration (if applicable) *
Highest Educational Level Completed *
Reentry Goals (check all that apply) *
Educational Attainment Goal *
Programs of Interest *
Are you currently enrolled in a program of higher education? (vocational, 2-year college, 4-year college, etc) *
If yes, please include the (1) name of the school/college/university, (2) your major, (3) approximate start date, and (4) anticipated year of completion
Schools of Interests (List up to 3 or state not applicable if none)
List your top 3 strengths *
List your top 3 areas of improvement *
What are you passionate about? *
What do you want to do for your career? *
Do you currently have any reentry mentors or counselors? *
Support Contact: Please provide the name, phone number, email, and relationship of someone you can go to for support.
Have you defaulted on student loans? *
I agree to the following (check all that apply). Workshop and mentoring are required for eligibility for scholarships: *
Main area of Focus: The program provides educational counseling and mentoring to justice-involved individuals by addressing 4 main areas of focus: College Readiness & Career Development (CRCD), Leadership Skills (LS), Admissions & Financial Aid Counseling (AFA), & SAT/ACT/GRE (SAT) Preparation. Would you be interested in our workshops? * *
Are you currently employed? *
If you are employed, please list name and location of your employer.
What is your monthly income?
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What is the total of your monthly expenses (roughly)?
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Do you have any financial support from family or friends?
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Do you have stable housing? (in this context) Stable housing is a reliable and secure place of shelter to reside and sleep for at least 6-12 months. *
Housing type
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Zip Code of housing where you reside *
Full Address of housing where you reside
Date of Birth *
Race & Ethnicity *
Electronic Signature (Full name). If you attest that the information provided is true to the best of your knowledge, please provide your full name. * *
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