Open Gate Inc

PARTICIPANT APPLICATION


Name: * Name	Date: * Date
Address: * Address	Referring Agency:
Phone Number: * Phone Number Required	e-Mail:
CDCR #: CDCR #	Date of Birth: Date of Birth:
Gender: Gender: MaleFemale
Ethnicity/Race: Ethnicity/Race:	Native Language: Native Language
Marital Status: Marital Status:	# of children: * Number of children
Emergency contact name and phone #: Emergency contact name and phone #:
Veteran of US Armed Forces: Veteran of US Armed Forces:YesNo	Registered with Selective Service: Registered with Selective ServiceYesNo
Disability: Disability: None Mobility Developmental Learning (reading/comprehension) Visual Speech Hearing	Medical Conditions (check all that apply): Medical Conditions (check all that apply): Dialysis Heart Problems Diabetic Hypertension Other(s)

Were you ever in a substance abuse program? Were you ever in a substance abuse program? YesNo	If so, please indicate programs: If so, please indicate programs:STARD.E.U.C.E.Other:

Education Completed: Education Completed: High School Diploma: GED / HISET AA Degree BA Degree Some college	Were you ever expelled from school? Were you ever expelled from school? YesNo
Age at first arrest: Age at first arrest:	of arrests: of arrests:
Number of probation or parole violations in the past 6 months: Number of probation or parole violations in the past 6 months:	Last violation/date/# of days served: Last violation/date/# of days served:

Are you currently employed? Are you currently employed? YesNo	If so, name of employer? If so, name of employer?
Have you been terminated from a job? * Have you been terminated from a job? YesNo	If so, why? If so, why?
Have you ever been employed for more than 6 months constitutively? Have you ever been employed for more than 6 months constitutively? YesNo	Job Skills / Certifications: Job Skills / Certifications:
Employment Goal: Employment Goal: Professional Technical Managerial Clerical Sales/Customer Service Sales/Customer Service Agriculture Skilled Labor Construction Food Industry/Hospitality	Goals you would like to accomplish as an Open Gate participant: Goals you would like to accomplish as an Open Gate participant: Obtain GED/HISET/High School Equivalency Secure Employment Vocational Training and Certification Enroll in college to obtain AA degree Enroll in college to transfer to a university to obtain BA degree
Check one that best describe your current living situation: Check one that best describe your current living situation: Sober Living Resident County Drug or Alcohol Program HousingRent: Apartment / HomeOwn Your HomeFriends or RelativesHotelShelterHomelessOther	Type the following: For security purposes, please type the letters in the image.