Name
*
First Name
Last Name
Nick Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Non-binary
Other
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email
*
example@example.com
How did you hear about Inspire?
Do you have a Driver's License?
*
Yes
No
Do you have a car?
*
Yes
No
Car Make/Model
Year
Monthly Payment Amount?
How well does your car run?
Highest level of education:
*
Date of HS Graduation or GED?
*
-
Month
-
Day
Year
Date
Have you applied for FAFSA?
*
Yes
No
Do you have a job?
*
Yes
No
Total Monthly Gross Income:
*
List all sources of monthly income:
*
List all credit card debt:
*
Are you coming out of:
*
Foster Home
Guardian Home
Homeless
AB12
*
Yes
No
Unsure
Last county or Agency Social Worker's Name and Phone Number:
Which county manages your case?
Name and phone number of Life Coach/ILP Worker:
What college or vocational school are you planning on attending?
*
What major are you thinking about declaring?
*
Have you ever been convicted of
Misdemeanor
Felony
None
Are you currently on probation?
*
Yes
No
If yes, when will it end?
Do you have a history of drug use? (this may not prevent you from being accepted)
*
Yes
No
Have you ever been hospitalized for mental health reasons?
*
Yes
No
If yes, please give the approximate dates and explain
Do you have a current mental health diagnosis?
*
Yes
No
Please tell us about your history. What brought you into foster care and/or homelessness? (This should be 1-3 complete paragraphs)
*
Do you have any family members that you keep in touch with and what do those relationships look like?
*
What is your current education, employment and living situation?
*
What are your goals for the future?
*
How do you see Inspire helping you to reach your goals?
*
I certify that all the above information is true and accurate to the best of my knowledge, and I give permission for Inspire to verify the above stated information including and not limited to a credit report.
*
Please attach all transcripts:
*
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Please attach one personal reference from a teacher, employer, social worker, counselor or other mentor in your life:
*
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