The Almond Connection Program Application
The information provided in this questionnaire is for the sole use of The Almond Connection and will not be shared with any person or organization without expressed, written permission from the applicant and The Almond Connection. Applicants will be advised if they are accepted in The Almond Connection (TAC) two-year program consisting of three stages preparing men and women who are judicially served with access to services to improve self-sufficiency. You are expected to be at court on any dates necessary. Please answer the following questions to the best of your ability. Fill in as much as possible, not all fields are required:
Today's Date
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Month
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Day
Year
Date
Full Legal Name
First Name
Middle Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is the best time to call you?
Birth Date
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Month
-
Day
Year
Date
Gender
Female
Male
Other
Valid Driver's License Number or State ID Number
Who or which organization referred you?
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Emergency Contact Information
Name
Address
City
State and Zip Code
Phone Number
Marital Status
Single
Married
Divorced/Separated
Widow/Widower
Documents to Obtain
Birth Certificate
SS Card
Driver's License
Other Photo ID
Court Records
Residence for Past Year
Parent or Guardian's Home
Other Relative/Friend's Home
Independent
Transitional Facility/Shelter
Treatment Facility
Correctional Facility
Foster Home
Unhoused
Do you have children?
Yes
No
If yes, please list their names and ages
Do you pay child support?
Yes
No
Check any that apply to you:
Children live with me
Children live with family member
Children live elsewhere
We need housing
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Legal History
Have you ever been arrested?
Yes
No
What are the specific charges? Please write case number(s) and dates?
Have you ever been convicted of a crime?
Yes
No
What are the specific charges? Please write case number(s) and dates?
Have you ever been in jail?
Yes
No
Have you ever been in prison?
Yes
No
Most recent Prison ID #
Most recent release date
Number of times in jail/prison as a juvenile
Number of times in jail/prison as an adult
Total time spent incarcerated as an adult
Are you currently on probation?
Yes
No
Are you currently on parole?
Yes
No
If yes to either of the above two questions, how long?
Name of probation/parole officer
Phone number of probation/parole officer
How often do you meet?
Were you or are you now involved with a gang? Explain.
Do you have access to a weapon?
Yes
No
Do you have any pending court dates?
Yes
No
If yes to above question, please fill in dates and case number
Do you have adequate transportation to court?
Yes
No - I will need help with transportation
Can you commit to being present for your court day(s)?
Yes
No
Other
Do you owe any court fines/fees? If yes, please list the amounts.
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Employment History
Are you currently employed? If yes, please write your employer's name. If not, would you like to be connected to resources that can assist you with employment?
Prior employment: List last two job positions with dates, duties, and salary.
Describe any work related skills
What are your future employment goals?
Education History
Highest Schooling Completed
Did not complete high school
Completed high school or received GED
Some community college or trade school
Associate's degree/Trade certificate
Some college/university
Bachelor's degree
Some graduate school
Graduate degree
Name of last school/college attended
Any future education plans?
Any skill deficiencies/barriers to successful learning?
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Physical and Mental Health History
Do you have health insurance?
Yes
No
Self Health Rating
Poor
Fair
Good
Excellent
Explain why you chose the self rating above
Are you working through any addictions? If yes, are you getting help? If not, would you like to be connected to resources that can help?
Do you have any mental health or other medical needs? Are there any medications you need? Would you like to be connected to resources that can help?
Explain any other health concerns
What medications do you take?
When did you last see a doctor?
Have you ever experienced any of the following? Check all that apply.
Physical abuse
Difficulty sleeping
Drug abuse
Alcohol abuse
Sexual abuse
Self-mutilation
Attempted suicide
Do you have supportive family members and/or a support system that can help you? Please share their name and phone number with us, so we may connect and coordinate with them.
By signing below I certify all information is true and correct to the best of my knowledge.
Signature
Date
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Month
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Day
Year
Date
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