Operation Freedom Package Registration Form
A Better Day Than Yesterday is dedicated to supporting returning citizens and their families. We offer support to justice impacted individuals thats been released from a correctional facility 2 years or less ages 18-65 years of age.
Email
*
example@example.com
Name
*
First Name
Last Name
Gender
*
Ethnicity
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What state are you needing services
Please Select
Virginia
Georgia
DMV
How did you hear about Operation Freedom Package? Please include the name of the person that referred you or the agency here
*
What Facility were you released from?
*
Release Date
*
Length of incarceration
*
Are you a Violent or Non Violet Offender?
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Violent
Non Violent
Are you a Veteran that's been incarcerated?
Yes
No
Are you a Veteran with Kids under the age of 17?
Yes
No
Are you a registered Sex Offender?
*
Yes
No
At this point in time what are your top 3 priorities?
*
Housing
We have affordable housing available in Henrico, West End, and Church Hill with single and shared living spaces. (Please note sponsor spaces are only for shared bedrooms.)
Do you need housing?
Please Select
Yes
No
Are you employed?
Please Select
Yes
No
Will you be self pay?
Please Select
Yes
No
Would you need a Sponsor for housing?
Please Select
Yes
No
Shared Space or Single Room
Please Select
Single
Shared
Are you a parent?
*
Yes
No
If so how old are your children? (If not, put N/A)
Would you be interested in our family programs?
Yes
No
Do you have a history of Mental illness?
*
Yes
No
Do you have a diagnosis for your mental illness? If so explain here. (If not, put N/A)
*
Do you need Substance Use Disorder Counseling?
Please Select
Yes
No
Are you homeless?
*
Yes
No
Other
If yes, how long have you been homeless?
Do you need crisis services?
Do you need clothing? Provide your pants ,shirt, undergarments ,coat size here.
Did the COVID-19 Pandemic cause you to be homeless?
Yes
No
Which of the following are most needed at this time?
Financial Literacy "Banking 101"
Credit Repair/Building
Health and Wellness
Health Insurance
Life Skills Development
Coping Skills
Conflict Resolution
Career Advantage 18-24
Career Advantage 24-65
Other
Are you interested in OAR's Ride2Reentry Program? (If you have a person that is interested in receiving a bike as transportation, they would need to call and register for intake (it's over the phone and takes less than 30 minutes.) Then they would just tell their case manager they want to do the Ride2Reentry class on a Friday. Sam will facilitate--clients (and Sam) must wash hands and wear masks. Class takes about an hour and a half and includes maintenance and safety. We hold class outside for up to 3 participants at a time. And they get to leave with their bike that day.)
Yes
No
Are you in need of food assistance?
Yes
No
Would you like a free haircut voucher?
Yes
No
Back
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Please upload your resident information sheet here from the facility you were released from. Thank you! WELCOME HOME!!!
Browse Files
Cancel
of
COVID - 19 Release I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that ABDTYIP has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.I further acknowledge that ABDTYIP can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families. I hereby release and agree to hold ABDTYIP harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself15and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from ABDTYIP. I understand that this release discharges ABDTYIP from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from ABDTYIP. This liability waiver and release extends to the salon together with all owners, partners, and employees.
*
Agree
Disagree
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