Filling the Gap Information Sheet

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To help inspire others with similar backgrounds as ourselves to excel beyond what society and life circumstances have set to be the norm. www.fillingthegapservices.com

Email *

Email Address *

First Name *

Last Name *

Best Phone Number *

Please share your social media handle

Purpose of Connection *

Prison to Professional Program (P2P)

Women In Transition Program (WIT)

Mentoring (Formerly incarcerated/Justice involved)

Become a Facilitator

Volunteer

WIT Pen Pal

Ban the Box/Advocacy/Policy

Training, Workshops, and Consulting

Speaking Engagement

Other:

Required

Do you have access to stable technology? *

Yes

Maybe

Other:

Are you filling this form out for someone else that is currently incarcerated or detained? If so, please state your Full Name and Relationship to the person.

Your contact number & email of person completing

Charge(s)/conviction(s), include date(s) of sentencing and release(s), ODRC # and location of incarceration (if applicable) *

Highest Educational Level Completed *

High School Diploma

GED

Some College Courses

Associates Degree

Bachelors Degree

Some Graduate School Courses

Graduate School Degree (MA, MS, MBA, etc)

Professional Degree (MD, JD, etc)

Doctorate Degree (PhD, EdD, DSW, etc)

Other:

Reentry Goals (check all that apply) *

Get accepted into college

Graduate from college

Reconnect with family

Obtain employment

Retain employment for one or more years

Stay drug free

Other:

Required

Educational Attainment Goal *

Complete GED

Associates Degree

Bachelors Degree (BS, BA, etc)

Masters Degree (MS, MA, MBA, etc)

Professional Degree (MD, JD, etc)

Doctorate Degree

Other:

Programs of Interest *

Are you currently enrolled in a program of higher education? (vocational, 2-year college, 4-year college, etc) *

Yes

Maybe

If yes, please include the (1) name of the school/college/university, (2) your major, (3) approximate start date, and (4) anticipated year of completion

Schools of Interests (List up to 3 or state not applicable if none)

List your top 3 strengths *

List your top 3 areas of improvement *

What are you passionate about? *

What do you want to do for your career? *

Do you currently have any reentry mentors or counselors? *

Yes

Maybe

Support Contact: Please provide the name, phone number, email, and relationship of someone you can go to for support.

Have you defaulted on student loans? *

Yes

Maybe

I agree to the following (check all that apply). Workshop and mentoring are required for eligibility for scholarships: *

Initial mentoring: At least 2 phone calls or text conversations per month.

15-minute phone calls (or text) bi-weekly as designated. To check in and see the progress on what we are working on.

We are starting a longstanding relationship. Even once the initial period is over, we will continue to stay in touch periodically.

I do not agree to the above or I do not wish to engage in a mentoring agreement.

Participate in the workshops for 4-6 weeks (electronically or in-person)

Other:

Required

Main area of Focus: The program provides educational counseling and mentoring to justice-involved individuals by addressing 4 main areas of focus: College Readiness & Career Development (CRCD), Leadership Skills (LS), Admissions & Financial Aid Counseling (AFA), & SAT/ACT/GRE (SAT) Preparation. Would you be interested in our workshops? * *

Yes

Maybe

Are you currently employed? *

Yes

Maybe

If you are employed, please list name and location of your employer.

What is your monthly income?

$0-$500

$500-$1,000

$1,000-$1,500

$1,500-$2,000

$2,000-$3,000

$3,000+

Other:

Clear selection

What is the total of your monthly expenses (roughly)?

$0-$500

$500-$1,000

$1,000-$1,500

$1,500-$2,000

$2,000-$3,000

$3,000+

Clear selection

Do you have any financial support from family or friends?

Yes

Maybe

Clear selection

Do you have stable housing? (in this context) Stable housing is a reliable and secure place of shelter to reside and sleep for at least 6-12 months. *

Yes

Maybe

Housing type

Homelessness (without reliable shelter to sleep and reside)

Transitional housing (half-way house, work-release, etc.)

Reside with family or friend (rent-free)

Rent (with family or friend)

Rent (with company, apartment, condo, etc)

Own

Other:

Clear selection

Zip Code of housing where you reside *

Full Address of housing where you reside

Date of Birth *

YYYY

Race & Ethnicity *

Black or African decent (Non-Hispanic)

White (Non-Hispanic)

Hispanic/LatinX

Asian

Native American or Pacific Islander

Other:

Required

Electronic Signature (Full name). If you attest that the information provided is true to the best of your knowledge, please provide your full name. * *

Send me a copy of my responses.

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