The Jack Brewer Foundation’s
2nd Chance Fatherhood Initiative
Participant Application
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SSN
Date of Birth
-
Month
-
Day
Year
Date
Cell Number
Please enter a valid phone number.
Secondary Number
Please enter a valid phone number.
Veteran
Yes
No
Branch
Have you lived in a recovery residence before?
Yes
No
If yes, where?
Where do you live now? Legal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your source of income? SSI
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Currently employed?
Yes
No
Name of Company
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor Name
Phone Number
Please enter a valid phone number.
Enrolled in college/University? Y/N
Yes
No
Days in Attendance
Do you own a car?
Yes
No
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Felony convictions?
Yes
No
What?
Felony convictions
When?
Felony convictions
Where?
Felony convictions
Have you ever been arrested for a sex crime or Arson?
Yes
No
Probation/Paroler?
Yes
No
Start Date
-
Month
-
Day
Year
Probation/Paroler
End Date
-
Month
-
Day
Year
Probation/Paroler
P.O. Name
Phone Number
Please enter a valid phone number.
Court case/Charges pending
Receive SSI or SSDI?
Yes
No
Medical Issues?
Yes
No
Brief the Medical Issues
Current Medications
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Age of first used drugs
Drug(s) of choice
Date of last use
-
Month
-
Day
Year
# of relapses in a year
Treatment Program Completed
Yes
No
How many?
If so which one?
Addictions of compulsive behaviours you have:
What kind of problems has drinking and/or drug use caused you?
Have you ever received a DUI?
Yes
No
How many?
Do you have problems with rules/authority?
Are you prejudiced towards any groups or race?
Have you ever experience suicidal thoughts?
Yes
No
If yes, how long ago?
Are you currently experiencing any suicidal thoughts?
Yes
No
If yes, have you thought of a plan?
Yes
No
If you answered yes to the previous suicide questions, do you agree to enter into a plan of action/safety if needed?
Yes
No
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Submit
Emergency Contact
Emergency Contact
Phone
Please enter a valid phone number.
Relationship
Emergency Contact
Phone
Please enter a valid phone number.
Relationship
STAFF USE ONLY
Applicant Accepted
Yes
No
Date of Intake
-
Month
-
Day
Year
Date
Move-in-Date
-
Month
-
Day
Year
Date
Participant Signature
Clear
Date
-
Month
-
Day
Year
Staff Signature
Clear
Date
-
Month
-
Day
Year
Should be Empty: