PROGRAM APPLICATION

PERSONAL INFORMATION

Name Social Security #: - -

Address Home Phone #:

Mess. Phone #:

Citizenship: U.S. or other Date of Birth:

Ethnicity: Gender: Male Female

Are you attending any school, GED course, college or vocational training? YES NO

If so, what school are you currently attending?

BACKGROUND INFORMATION

Probation/Social Worker’s Name Probation/Social Worker’s Phone #

(Current or Previous)

Type of placement: (Current or most recent placement)

Address

Length of time in placement: Emancipation Date (or expected):

ASSISTANCE INFORMATION

Have you ever received assistance from the Independent Living Program? YES NO

If so, briefly describe:

Are you currently receiving any other type of income? If yes, briefly describe: (welfare, financial aid, social security, etc.)

Are you currently employed or enrolled in an employment program? YES NO

If so, please provide the following information:

Starting Date

Employer

Position

Hourly Wage

Please circle or state the type of assistance you are requesting:

HOUSING WORK CLOTHES FOOD TRAINING COSTS

OTHER:

Please estimate the amount of assistance you are requesting: $

Signature: __________________________________________Date: