The Gap Home Application Form

Application

Thank you for your interest in The Gap Home. Other requirements for entry into our program include: phone interview, drug screen, medical test results, identification, and additional information depending on needs. If you do not hear from us in three business days, please call 769-242-9044. Mothers may bring sons who are 9 and younger, and daughters of any age.
Full Name*

First NameMiddle NameLast Name
Nickname AKA or Maiden name

First NameLast Name
Birth Date*

MonthDayYear
Gender at birth*

malefemale
Social Security Number*
Mobile Number*
Telephone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your E-mail*
example@example.com
Repeat same e-mail address for verification*
example@example.com
This e-mail field must match "Your E-mail"
example@example.com
Be sure "Your E-mail" is correct and these fields match
example@example.com
Person to contact in case of emergency*
Phone Number of Emergency Contact*
Relationship*
ex: Father, Sister, etc.
Address of Emergency emergency*
I would like to have my minor children

Live with meVisit me overnight
I have this many daughters:
I have this many sons 9 or younger:
I have this many sons 10 to 12 years old: Please note that sons 13 and older may visit everyday, but cannot do overnight stays.
Current level of education or training
High School

Yr1Yr2Yr3Graduated
GED

Yes
College

Yr1Yr2Yr3Graduated
Tech

IncompleteCompleted
Other education or training
Would you like further training or education?
In what field would you like training or education?
Would you like to take a career or skills assessment test?
Fees Information

Give details of who will pay your fees.
Who will pay your fees?*

YourselfSponsor or Family memberOrganization
Name & address to which invoice is to be sent*
Phone Number*
Program Attendance

Give details of the recovery program you attended, even if you're incarcerated.
What date did you begin and end this program (specify future date of completion if applicable)*
Name and Address of Facility*
Phone Number
How long was the program?
Did you complete the program?*

YesNo
If no, what was the reason for not completing?
What was your main struggle while in the program?
Name of Director, Mentor, or Contact
Have you been sober for six months or longer?*

YesNo
How long have you been sober?
Employment

Please give details of previous employers with dates.

	Organization	Position held or summary of responsibilities	From (mm/yy) to (mm/yy)
1
2
3

Statement In Support Of Application

This section must be completed. You should state why you want to undertake our program, any relevant experience, skills and attributes, and your long terms goals while in our transitional home.
References

All applicants must provide one reference. An employee or volunteer of the program you just completed, pastor, or a former employer, etc.
Reference 1*
Phone Number*
Organization
How do they know you:
Reference 2
Phone Number
Organization
How do they know you?
Please tell us how you found out about us
Do you have a physical or other disability, medical condition or require learning support?*

YesNo
If yes, please name and give brief details
Legal
Have you ever been arrested?*

YesNo
Are you on parole or probation?*

YesNo
If Yes, how often do you report?
PO's Name

First NameLast Name
PO's Phone Number
PO's Email
example@example.com
Are you currently incarcerated?*
If so,
How long is your sentence blanks
When is your expected release blank
If you have an exact date of release, what is it blank
Have you been convicted of*

any sexual crimeany violent crimenone of the above
If so, what is your MDOC # or identification number?
If so, Case Manager's Name

First NameLast Name
Case Manager's Phone Number
I understand a phone interview, medical and drug tests, legal photo identification, and financial obligations must be provided to enter the Gap Home transitional housing & life skills program.
Type your name to indicate your understanding
Declaration

I certify that, to the best of my belief, the information I have provided is complete and true.
Signature of Applicant

First NameLast Name
Date

monthdayyear
Should be Empty:

Application

Current level of education or training

Fees Information

Program Attendance

Employment

Statement In Support Of Application

References

Legal