HOB Application

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Current Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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
Curaçao
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
United States
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
4
Is your current living situation permanent? If not, what is your move out date?* This field is required.
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Email
example@example.com
7
Preferred method of contact* This field is required.
phone (call)
phone (text)
email
8
Do you have a valid photo ID?
YESNO
9
Other Places You Have Lived (cities, states, etc)* This field is required.
10
How did you hear about House of Bread?
11
Do you have children?* This field is required.
No
Yes, grown or living with someone else
Yes, living with me
12
What is your highest education level?* This field is required.
Highschool diploma
GED
College or vocational training
None of the above
13
What is your current method of transportation?
14
Please describe any mental health issues you have faced in the past or continue to struggle with. Describe any treatments you have received or are receiving currently for any mental health issues.* This field is required.
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Ok
15
Please describe and explain any past issues of drug or alcohol abuse including any treatment facilities or twelve step program you are now or were a part of in the past. Why are you now committed to remaining sober and clean?* This field is required.
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Ok
16
How long have you been sober?
17
Do you have any warrants, upcoming court dates, or outstanding legal issues?* This field is required.
YESNO
18
Have you ever been convicted of a felony?* This field is required.
YESNO
19
Total amount of time spent incarcerated?* This field is required.
20
Most recent release date?
21
Are you currently on probation?* This field is required.
YESNO
22
Are you currently employed?* This field is required.
YESNO
23
If you are currently employed, tell us about your job. If you are not employed, are you currently seeking employment?* This field is required.
24
Have you ever received ServSafe Certification?* This field is required.
YESNO
25
Why do you want to participate in House of Bread?
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Ok
26
As part of the program, you will be paired with a mentor who can support you in resume writing, job searching, connecting with community resources like food pantries, GED courses, etc. What would you like to work on with your mentor?* This field is required.
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Ok
27
House of Bread is a faith-based organization and there is a spiritual growth component to the program. Participants of all faith backgrounds are welcome. Do you have any questions or concerns about the faith component of the program?* This field is required.
28
We are currently holding classes and baking on Monday and Wednesday mornings. Does your schedule allow you to participate between 9 AM and 12:30 PM on those days? If not, please explain.* This field is required.
29
Students in the program will be asked to meet with a mentor once a week outside of class. Which of the following times would you be available? Please check all the times you can possibly be available.
after class on Monday
weekday evenings
after class on Wednesday
weekends
Tues, Thurs, or Fri mornings
Tues, Thurs, or Fri afternoons
30
Is there anything else you would like us to know about you?
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