Program Participant Application

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Program Participant Application

* Indicates required field

Today's Date *

DD/MM/YEAR

(DD/MM/YEAR)

Name *

First

Last

Date of Birth *

DD/MM/YEAR

Social Security Number: *

xxx-xx-xxxx

Gender *

Ethnicity *

Phone Number *

Secondary Phone *

Email Address *

Marital Status *

Single Married

Number of Dependents *

Who is nominating/referring you to A Seat at the Table?

Name *

First

Last

Title *

Organization *

Where are you living now?

Street Address *

City *

State *

ZIP/Postal Code *

How long have you lived there? *

Have you been asked to leave? *

If so, please explain briefly.

If you have a valid driver’s license, please provide your license #, state, and expiration date:

License Number *

State *

Expiration Date *

DD/MM/YEAR

Do you have a car? *

Yes No

Emergency Information

Emergency Contact Name #1 *

First

Last

Phone Number *

Relationship *

Emergency Contact Name #2 *

First

Last

Phone Number *

Relationship *

Education Information

Highest Grade Level Complated *

List any certifications or licenses *

Employment History

Current Employment Status *

Employed Unemployed

Current Employer *

(if unemployed leave blank)

Employed Since *

DD/MM/YEAR

Hours/Week *

Pay Rate/Salary *

Secondary Employer *

Employed Since *

DD/MM/YEAR

Hours/Week *

Pay Rate/Salary *

Finances

Additional Income Sources *

Type of Debt *

Student Loans Credit Cards Car Loans Personal Loans Payday Loans Eviction Past Due Utilities Restitution Legal/Court Costs Unpaid Taxes

Check all that apply.

Other *

Please describe

Misc. Information

Is a social services Case Worker currently assigned to you? *

Yes No

If yes, provide contact info for your Case Worker:

Name *

First

Last

Email *

Phone Number *

Veteran? *

Yes No

Disabled *

Yes No

Do you use drugs or alcohol? *

Yes No

Tobacco Use *

None Cigarettes Cigars Pipe Chewing Tobacco Snuff Vaping

Check all that apply.

Have you ever been in rehabilitation? *

Yes No

Alcoholics Anonymous Participant? *

Yes No

Narcotics Anonymous *

Yes No

Have you ever been a battered person? *

Yes No

Have you ever been arrested? *

Yes No

If previously arrested, provide details *

Where/When/For what charges/Outcome of charges?

Do you have any outstanding traffic tickets? *

Yes No

If yes, provide details *

Are you currently on parole or probation? *

Yes No

Is there a current warrant for your arrest? *

Yes No

Applicant Statement

Please briefly describe your current and past living arrangements *

Please explain why you are interested in our program *

Agreement and Disclosure

Signature *

Submit

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Admin

Who We Are
How It Works
- Our Process
- Our Partners
Get Involved
News & Events
Apply
- Program Participant Nomination
- House Parents’ Application
Donate