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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

1. Please check the programs that you are interested in (you can check more than one option):

Parenthood Development
Child Support and Courthouse Navigation
Financial Literacy

2. Please share some personal information with us to help us serve you better.

First Name

Last Name

Date of Birth

calendar

Age This question requires a valid number format.

Are you homeless?

Address

City, State, Zip

Home Phone

Mobile Phone

Is it OK to text you?

Email Address

Gender

Race/Ethnicity

Are you working?

If yes, where are you working?

How long have you been employed in this job?

Work Phone

Do you have transportation?

Are you licensed and insured to drive?

Are you currently receiving any income?

If yes, please explain

Have you ever been in the military?

If yes, have you been discharged?

Please describe the nature of your discharge. Was it an honorable or dishonorable discharge?

What was your last year completed in school?

Have you completed any years of college education?

Have you had any other training? Please explain

What is your primary language?

3. Please tell us about your family.

How many children do you have? This question requires a valid number format.

What are their ages?

What is your marital status?

Spouse's name

Spouse contact phone

Emergency Contact person

What is your relationship to this person?

Emergency Contact Primary Phone Number

Emergency Contact Secondary Phone Number

Emergency contact address

4. Please tell us about your legal history.

Have you ever been arrested?

Have you ever been incarcerated?

If yes, where were you incarcerated and for how long?

Are you currently on probation or parole?

If yes, please provide your probation or parole officer's name and contact information

Do you have a child support case?

If yes, what county or state is the case in?

Do you have any legal charges pending?

If yes, where?

Do you have any other pending legal matters (including bankruptcy) that would require your attention in the next 90 days?

If yes, please provide some details.