Globally Love and Care Application

1
Name* This field is required.
First Name
Last Name
2
Email
example@example.com
3
How did you hear of us? * This field is required.
4
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number
Area Code
Phone Number
6
How old are you ?* This field is required.
7
Date of Birth * This field is required.
Date
Year
Month
Day
8
What is your gender preference?
9
What is your SS# * This field is required.
10
Are you currently working?* This field is required.
YESNO
11
If so, Where?* This field is required.
12
I.D. or D.L. Number* This field is required.
13
Have you been convicted of a crime other than a misdemeanor ?* This field is required.
YESNO
14
If so explain why?* This field is required.
15
Are you currently on Parole ?* This field is required.
YESNO
16
If so explain why* This field is required.
17
Are you currently on probation ? * This field is required.
YESNO
18
If so explain why?* This field is required.
19
Do you have any medical conditions ?* This field is required.
YESNO
20
If so which ones ?* This field is required.
21
Are you currently on any medications ?* This field is required.
YESNO
22
List Medication If any * This field is required.
23
Are you a client of any organization? ex. (T-Core, Capital Star, TLCS, ETC)* This field is required.
YESNO
24
If so, which one?* This field is required.
25
Have you ever been evicted from your home?* This field is required.
YESNO
26
If so, what was the reason?* This field is required.
27
What is your source of income?* This field is required.
28
Do you have any emergency contacts?* This field is required.
YESNO
29
Name and number
Name
Number
30
Name and number
Name
Number
31
Name and number
Name
Number
32
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SignatureI Understand All of my information will be treated with confidentiality and will only Be shared with authorized persons or agencies.a.An inspection of personal property will be conducted upon initial entry to the home. b.A random room check will be conducted. c.I must attend all house meetings, as well as “One on One” meetings. d.All questions, problems, etc... will be addressed to the house manager. e.Random drug testing will be conducted, if positive, immediate termination from the program. May have option return in fourteen (14) days with Director and peers approval. f.You will be re-tested and you must have negative results. g.I must inform the house manager of my whereabouts at all times. I must supply my schedule to the house manager. h.Smoking is permitted in designated areas only, (per procedural in smoking) i. The house manager will assign chores to me on a weekly basis. j.All phone calls are subjected to House Rules, (per procedural on phone calls) k.Quiet time begins at 10:00 p.m. (Televisions in common areas are to be turned off and all televisions in the bedrooms will be kept at low volume). Lights out no later than 11:00 p.m.( Including all the televisions in the house). Weekend exceptions may be made. l.Curfew is 10:00 pm Sunday-Thursday, 12:00 midnight on Friday-Saturday. The House manager must be notified if you will not be home at least one hour prior to curfew. Doors are locked for the evening after curfew time. You must re-enter the home at 6:00 a.m.the following morning.m.Absolutely no pets of any kind are allowed in or on the premises without express consent from the Director, for health and safety issues. Violation of these rules will result in your loss of that privilege for one week. A second violation will result in a one-month loss of your privilege. A third violation denotes willful non-compliance and will result in immediate termination from the house. We reserve the right to terminate clients from the program at any time and without prior and/or written notice, if the individual has been found in non-compliance with any of the rules and regulations. By signing, I am stating that I fully understand and agree to co-operate with the terms of the rules and regulations.
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