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Application for Life School & Residency
Please Read First. You must answer every question, otherwise your application will
not be considered. If a question is not applicable, indicate with “N/A” or “None”.
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* Indicates required question
Name
*
Your answer
Email
Your answer
Phone Number
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Social Security Number
Your answer
ID/SID/TJD#
Your answer
Height
Your answer
Weight
Your answer
Dress Size
Your answer
Shoe Size
Your answer
Languages
English
Spanish
Other:
Name of Nearest Relative
Your answer
Relative's Phone Number
Your answer
How did you hear about Lifeway Haven?
Your answer
Have you applied before?
Yes
No
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Have you had your parole board hearing
Yes
No
Clear selection
Have you been granted parole?
Yes
No
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If yes, what is your expected release date?
MM
/
DD
/
YYYY
List any required stipulations after release (monitor, Celebrate Recovery, AA...).
Your answer
Charges (Include all present and past violations, traffic violations and date of each violation.)
Your answer
Number of times you have been incarcerated?
Your answer
Total number of years/months you have been incarcerated?
Your answer
How many disciplinary write-ups (cases) have you had over the past two years?
Your answer
List reason and date of all major disciplinary cases since you have been incarcerated:
Your answer
List all self-improvement programs (personal growth) you have completed while incarcerated. Please list them in the order you felt were most beneficial to you.
Your answer
List work/training skills you have learned while incarcerated:
Your answer
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