Participant Profile Form

Participant Profile Form
Participant Profile
Name
Date of Birth

MonthDayYear
Date
Justice Involvement Identification Number (ex. DCDC ID, FBOP ID)
Home Phone
Cell Phone
Email address
Home Address (inc. city, state, zip code)
Demographic Information
Gender
Race
Ethnicity
Sexual Orientation
Marital status
Highest Level of Education
Religion /Spirituality
Social Security Number
Are you a veteran?

YesNo
List any languages spoken
Emergency Contact Information
Emergency Contact Name
Emergency Contact Phone Number
What is your relationship to your emergency contact?
Attachments
Please email info@vscdc.org with copies of any of the following documents that you have access to:
- Jail / Prison ID
- Social Security Card
- Release Papers
- Birth Certificate
- Drivers License or Non-drivers ID
- Medicaid / Health Insurance Card
Mailing Services
VSC Unique Identifier
As client of VSC, you are welcome to use our address on a temporary basis until you locate a permanent address of your own. Our mail policy is as follows: We will accept mail addressed to you and keep it in a safe and secure location.

We ask that you pick up your mail during our drop-in hours. Monday through Friday, 9:30AM to 3:30PM;

You are welcome to call VSC to see if you have any mail between the hours of 9:00AM to 3:00PM, Monday through Friday.
Mail that has not been picked up for a period of 6 months or more will be considered abandoned. Mail marked "Do Not Forward" will be returned to sender. The remaining mail will be destroyed. Should you be unable to pick up your mail, you must call and notify us so that we can know what to do with your mail.

Mail that is marked "Do Not Forward" will not be forwarded to you at another address; and under no circumstances can you use our address as an office address for the purpose of establishing or engaging in any business ventures.

By signing below, I understand the guidelines for using VSC's address as my mailing address and will abide by their policy.
Do you need to use VSC as a temporary mailing address?

YesNo
Signature

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Participant Profile Form

Participant Profile

Demographic Information

Emergency Contact Information

Attachments

Mailing Services