• Life Learning Center Candidate Intake Application

  • Referral

  • Identifying Information

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  • Emergency Contact

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  • Demographics


  • Household & Family


  • Criminal Background

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  • Housing & Transportation


  • Substance Use & Recovery

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    Pick a Date




  • Health Coverage

  • Physical Health


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  • Mental Health


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  • Public Benefits


  • Employment

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  • Pre-Program Self-Assessment

    The Life Learning Center program addresses the five domains of life (physical, emotional, relational, financial, and spiritual) to promote hope and dignity amongst Candidates.

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  • Photo Release and Right to Privacy Agreement

    By signing below, I consent to the use of my picture or image by the Life Learning Center for the purposes of illustration, advertising, video programming, or publication either alone or in connection with photographs and/or videotape of other persons or objects.

    I release all employees of the Life Learning Center from any and all liability of every nature arising from such use.

    With my signature, I also acknowledge my understanding that the information requested from me will be used by the Life Learning Center to improve my employment opportunities and change journey. I understand that my personal information may be shared with other partners, providers, and/or employers to enhance my opportunities for growth.

  • Clear
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    Pick a Date
  • Photo & Media Release

  • Clear
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    Pick a Date
  • Confirmation

    BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

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