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First name
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Tribe
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ID TYPE TRIBAL/STATE/ODOC:
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ID#
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Email
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Phone
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Birthday
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Month
Month
Day
Year
Sex
Male
Female
Multi-line address
Country/Region
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Address
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City
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Zip / Postal code
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INSTITUTIONAL INFORMATION
FACILITY/CORRECTIONAL CENTER
DOC#
CONVICTION
COUNTY OF CONVICTION
SENTENCE
RELEASE DATE
TYPE OF RELEASE
NEXT PAROLE HEARING DATE
Month
Month
Day
Year
CASE MANAGER
LENGTH OF INCARCERATION
JUVENILE RECORD
Yes
No
Choose one
PAROLE
PROBATION
COMMUTATION
PROBATION/PAROLE OFFICER
OFFICER #
ADDRESS
PROBATION FEES AMOUNT
PAID UP TO DATE
Yes
No
HOW MANY TIMES DO YOU HAVE TO CONTACT YOUR PROBATION OFFICER?
PLEASE TELL US ABOUT YOUR CONVICTION IN DETAIL, AND WHAT LED TO YOUR RECENT INCARCERATION
NEEDS
SHIRT SIZE
PANT SIZE
SHOE SIZE
DO YOU NEED ADDITIONAL TOOLS/SPECIALTY ITEMS TO WORK IN YOUR TRADE?
Yes
No
DO YOU HAVE DRIVERS LICENSE?
Yes
No
IF NO, WHAT HAPPENED?
WHAT IS OR WILL BE YOUR MODE OF TRANSPORTATION?
IS YOUR TRANSPORTATION RELIABLE?
Yes
No
HAVE YOU EVER USED PUBLIC TRANSPORTATION?
ARE YOU WILLING TO ACCEPT MENTORING, COUNSELING, AND LEADERSHIP TO GET YOUR NEEDS MET?
Yes
No
WHAT TYPE OF DOCUMENTATION DO YOU NEED FOR IDENTIFICATION PURPOSES?
SOCIAL SECURITY CARD
DRIVERS LICENSE
STATE ID
CDIB
BIRTH CERTIFICATE
TRIBAL CARD
ARE THERE ANY OTHER NEEDS THAT HAVE NOT BEEN LISTED?
PLEASE SELECT ALL THE SERVICES YOU HAVE APPLIED FOR
ADULT PROTECTIVE SERVICES
TANF
EMPLOYMENT AND TRAINING
CHILD SUPPORT
SOCIAL SERVICES
COMMODITIES
CHILD CARE
HIGHER EDUCATION
LEGAL SERVICES
TERO
HOUSING
CHILDREN AND FAMILY
FOOD STAMPS
MEDICAID
MEDICARE
HAVE YOU RECEIVED ANY OTHER REINTEGRATION SERVICES? IF YES PLEASE EXPLAIN
EMPLOYMENT AND EDUCATION
WHAT IS YOUR PREVIOUS WORK EXPERIENCE? HOW LONG AND DATES
DO YOU HAVE ANY REFERENCES
DO YOU HAVE ANY CERTIFICATIONS, DIPLOMAS OR DEGREES?
Yes
No
CAN YOU PROVIDE COPIES IF YES?
Yes
No
ARE YOU INTERESTED IN ANY VOC TRAINING?
Yes
No
IF YES, WHAT ARE YOUR INTERESTS?
HAVE YOU EVER ATTENDED COLLEGE OR VO-TECH?
Yes
No
IF YES, WHAT ARE THE DATES AND WAS YOUR MAJOR?
PLEASE SELECT IF YOU HAVE EVER APPLIED/USED ANY ASSISTANCE WHILE EDUCATION TRAINING
PELL GRANT
TRIBAL TUITION ASSISTANCE
SCHOLARSHIPS
STUDENT LOANS
VOCATIONAL REHABILITATION
ANY OTHER ASSISTANCE?
IF YOU RECEIVED ANY STUDENT LOANS, WHAT IS THE STATUS?
WHAT PROGRAMS HAVE YOU COMPLETED WHILE INCARCERATED?
MEDICAL AND MENTAL HEALTH
DO YOU HAVE ANY TYPES OF DISABILITIES THAT WOULD IMPAIR EMPLOYMENT: IE: DIABETES, HYPERTENSION, HEART ATTACK, STROKE, DOCUMENTED SUBSTANCE ABUSE, DOCUMENTED MENTAL HEALTH, DECREASED MOBILITY, OR PHYSICAL LIMITATIONS? PLEASE EXPLAIN
WHEN WAS YOUR LAST PHYSICAL EXAMINATION?
RESULTS OF EXAMINATION
WHAT CLINIC/HOSPITAL OR PRIMARY CARE OFFICE DO YOU USE OR WOULD LIKE TO
DO YOU CURRENTLY REQUIRE MEDICAL ASSISTANCE OR MEDICATION? IF YES WHAT?
DO YOU USE OR HAVE PREVIOUSLY USED ALCOHOL, DRUGS INCLUDING MARIJUANA, OR TOBACCO?
DO YOU HAVE OR HAVE YOU PREVIOUSLY HAD ANY ADDICTIONS TO ALCOHOL, DRUGS OR TOBACCO? IF YES WHAT?
WHAT IS YOUR DRINK OR DRUG OF CHOICE?
DO YOU FEEL YOU HAVE AN ACTIVE ADDICTION? IF YES WHAT?
IF SOBER HOW LONG HAVE YOU BEEN CLEAN?
WERE YOU UNDER THE INFLUENCE OF ANY SUBSTANCES DURING THE TIME YOU WERE ARRESTED FOR YOUR ALLEGED CRIME?
ARE YOU PHYSICALLY ABLE TO PARTICIPATE IN COMMUNITY SERVICE AND/OR VOLUNTEERING?
Yes
No
ARE YOU WILLING TO BE SUBJECT TO RANDOM URINALYSIS TESTING DURING YOUR TIME IN OUR PROGRAM? * SAYING NO MAY SUBJECT YOU TO DENIAL OF ENTRY TO THE “OFF THE REZ PROGRAM
Yes
No
ANY OTHER MEDICAL INFORMATION YOU WOULD LIKE US TO KNOW?
ADDITIONAL INFORMATION
ARE YOU A VETERAN?
Yes
No
IF YES, WHAT BRANCH AND TYPE OF DISCHARGE?
DO YOU HAVE A SPECIFIC RELIGIOUS AFFILIATION?
HOW DID YOU HEAR ABOUT NATIVE WINGS?
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