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Reconnection Center Registration Form

Page One

Please complete this registration form so you can participate in our programs
Click SUBMIT at the end to send us the information
Please complete this registration form so you can participate in our programs
Click SUBMIT at the end to send us the information
1. Please check the programs that you are interested in (you can check more than one option):
2. Please share some personal information with us to help us serve you better.
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This question requires a valid number format.
Are you homeless?
Is it OK to text you?
Gender
Race/Ethnicity
Are you working?
Do you have transportation?
Are you licensed and insured to drive?
Are you currently receiving any income?
Have you ever been in the military?
If yes, have you been discharged?
What was your last year completed in school?
Have you completed any years of college education?
3. Please tell us about your family.
This question requires a valid number format.
What is your marital status?
4. Please tell us about your legal history.
Have you ever been arrested?
Have you ever been incarcerated?
Are you currently on probation or parole?
Do you have a child support case?
Do you have any legal charges pending?
Do you have any other pending legal matters (including bankruptcy) that would require your attention in the next 90 days?
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