Welcome Home Central Valley
Supporting Change - Restoring Communities
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Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
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Gender
Male
Female
Address
Email
Phone
Referred to this program by
If completing this form on behalf of someone else, please provide your name
Primary Language (and other languages spoken)
ID Number
Current Correctional Facility (If Applicable)
Mailing Address of Facility (If applicable)
Current Conviction
Current sentence (If Applicable)
EPRD (If Applicable)
Attorney Name (If Applicable)
Length on Case (if Applicable)
Next Court Date (If Applicable) Please indicate the time,dept, and judge.
Housing
What is your plan for housing upon release?
Have you ever lived in Fresno
yes
no
Do you have family in Fresno. If so, where and who
Please list your last 3 living arrangements and if you held the lease
Have you broken a lease in the past
yes
no
Have you ever been evicted
yes
no
If yes to either of these questions, please explain:
Employment
What is your plan for employment/financial stability once released?
Please list the last 3 jobs you had (name and address of employer)and how they ended
What job skills do you posses
Restoritive Justice
Who has been affected by what you have done. In what way.
What have you done to foster personal growth since you’ve been incarcerated?
How have you worked on developing empathy for those affected by your crimes? If not, how do you plan to do so?
Personal
What is your religious preference/spiritual practice (if any)?
What are some hobbies or creative activities that you enjoy?
What skills, gifts, interests do you have [3]
About You
Single
Married
Divorced
Significant Other
Do you have children? If so, are you in contact with them?
What will be your greatest areas of need
Housing
Employment
Pro-Social Engagement
Mentor-ship
Medical
Education
Transportation
What other areas would you like to have support with?
Please use this space to share anything else you believe may be relevant to your application.
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