Operation Freedom Package Registration Form
A Better Day Than Yesterday is dedicated to supporting returning citizens and their families.
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
How did you hear about Operation Freedom Package? Please include their name or agency here
*
Release Date
What Facility were you released from?
Length of incarceration
Are you a Violent or Non Violet Offender?
Violent
Non Violent
Are you a registered Sex Offender?
Yes
No
At this point in time what are your top 3 priorities?
*
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)
*
Are you homeless?
*
Yes
No
Other
If yes, how long have you been homeless?
Do you need clothing? Provide your shoe, 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
Cell Phone/ Smart Phone Training
Life Skills Development
Coping Skills
Conflict Resolution
Career Advantage 18-24
Career Advantage 24-65
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? We are able to facilitate some grocery deliveries, please make sure they have a working cell phone or correct address if we are to provide them with this service.
Yes
No
Would you like a free haircut voucher?
Yes
No
Any other notes
Please upload your resident information sheet here from the facility you were released from. Thank you! WELCOME HOME!!!
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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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