Life Preservation Program Preliminary Application

Last name*

First name*

Birthday*

Month

Day

Year

Current Address*

Phone

May we text you?

Yes

No

Email*

Relationship Status*

How many children do you have that are currently in your custody?*

Are you currently pregnant?*

Yes

No

When is your due date?

Education*

Employment Status*

Have you been clean and sober for 2 weeks or longer?*

Yes

No

Are you currently on Probation or Parole?*

Yes

No

Have you ever been in Rehab of any kind?*

Yes

No

Have you ever been convicted of a felony?*

Yes

No

Disclaimer

I certify that all my answers are true and complete to the best of my knowledge.

I understand that false or misleading information in my application or interview process may result in my denial to the Life Preservation Program.

Signature*

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