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RE-ENTRY SUPPORT SERVICES APPLICATION '24
Thank you for your interest in our services! Please fill out this form and one of our representatives will contact you as soon as possible. (Hours of Operation Mondays - Friday 10AM-5PM)
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* Indicates required question
DC# (if applicable) If NOT applicable put (N/A)
*
Your answer
Name
*
First and last name
Your answer
Phone number
*
Your answer
Email
Your answer
Address
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Demographics - Gender
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Male
Female
Non-Binary
Transgender Woman
Transgender Man
Other:
Demographics - Race
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African American
Caucasian
Hispanic / Latino
Native American
Asian
Pacific Islander
Other:
What services do you need? Click all that apply
*
Clothing & Hygiene Package
Food Bank Navigation
Healthcare
Job Placement
Transitional Housing Navigation
Drivers License Restoration
Referral for Legal Assistance
Community Service Hours
Mental Health Services
Anger Management
Banking & Budgeting
Vocational Trade Education
Other:
Required
If you chose the clothing package- Please provide your shirt size, pants size, and shoe size.
(Restricted to Broward County & Dade County)
*
Your answer
Were you convicted of a violent crime?
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Yes
No
Were you convicted of a violation of probation or supervised release?
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Yes
No
Were you convicted of a sexual offense?
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Yes
No
Were you convicted of an offense involving a firearm?
*
Yes
No
Are you filling out this form on someone's behalf?
*
Yes
No
If you answered YES above- what is your name and relationship to the applicant? (Ex. mom, dad, sister, boyfriend, case worker ect.)
Your answer
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