APPLICATION
The information disclosed in this application form will not be shared with any entity outside of the TWM E.M.E.R.G.E. programme.
Name
*
First Name
Last Name
Other Name
Alias or Nickname
Date Of Birth
*
-
Day
-
Month
Year
Date
Phone Contact #
*
Please enter a valid phone number.
Format: (268) 000-0000.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City - St John, St Mary, St Philips, St Peter, St George, St Paul, Barbuda
State
Zip Code
Referral. Please check each person/agency that has referred you toTWM EMERGE:
Self
Court
Social Service Agency, e.g. PDV, WAR, DoGA, Board of Guardians, etc.
Pastor/Priest/Spiritual Advisor
Friend
Spouse/Girlfriend
Other Family Member
Employer
Other
What days are you available to participate in the EMERGE programme? Check all that apply.
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What time of day is available for you to participate int eh EMERGE programme? Check all that apply.
*
Morning. 9 am - 12 pm
Afternoon 1pm - 4pm
Evening 5pm - 8pm
Where have you heard about EMERGE? Check all that apply.
TV
Radio
Newspaper
FaceBook
Poster
Word of Mouth
Other
The TWM E.M.E.R.G.E. office is located on the second floor of a building. Are you able to walk up 2 flights of stairs?
*
Yes
No
EMERGENCY CONTACT INFORMATION
Emergency Contact:
First Name
Last Name
Relationship to you:
Friend
Spouse
Parent
Other Family Member
Employer
Other
Contact #:
Please enter a valid phone number.
Format: (268) 000-0000.
Email:
example@example.com
Please share any additional information that is relevant to your application:
Upload a picture or copy of your Government-issued photo ID. For example passport, elector's i.d. card, social security card or driver's license.
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I agree that the information provided in this form is true and correct. By submitting this application I am agreeing to participate in an in-person interview with a Case Manager, have my arrest and conviction history shared to TWM by the Royal Police Force of Antigua and Barbuda, and participate in a psychological screening. I understand that having a criminal history will NOT disqualify me from the EMERGE program. I understand that after the first meeting, the Case Manager will continue to review my social background, including receiving information from other social service agencies, e.g. probation. All of the information collected will be used to help me develop my personal goals. I understand that my personal information will remain confidential and will not be shared outside of the EMERGE program. I know that I have the right to stop participating in the application process if I choose to and can do so by alerting the Case Manager or Program Coordinator about my decision.
*
YES
No
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