Housing Application

Please fill out the following application.  If you would like to fill it out manually you can download from our forms section in the media center.

 
Name *
Name
Sex *
Birthdate *
Birthdate
Release Date
Release Date
Please enter the facility which you are coming from
Please enter your Parole or Probation Officer
Enter what charges in which you were convicted
Parole Discharge Date
Parole Discharge Date
Do you have a Drivers License or State ID
Please enter County, City and State of Birth
Enter Your Fathers Name *
Enter Your Fathers Name
Is father still living?
Enter your Mother's Name
Enter your Mother's Name
Is your mother still living? *
Marital Status *
Do you plan to return there after F.I.S.T. Program? *
Do you have any children? *
Enter the ages of your kids
Do you pay child support? *
Are you religious?
If you are religious, do you attend church?
Enter Name and City/State
Enter name and City/State
If graduated or GED, please enter approximate date
If graduated or GED, please enter approximate date
Do you plan on continuing your education? *
How long was the longest you were employed? *
Are you a veteran?
Do you have any medical conditions that require doctor's care? *
Would this medical condition prevent you from seeking employment?
Are you currently disabled? *
Do you receive disability benefits?
Have you ever been hospitalized? *
Enter text here
Will you be receiving any financial assistance from family? *
Enter text
Have you ever had a checking account? *
Have you ever had a savings account? *
Have you ever owned property? *
Do you currently owe fines, restitution to any public entity? *
Are you in need of financial counseling or creating a budget? *
Have you ever been diagnosed with a mental illness? *
Are you under the care of a psychologist or psychiartrist?
Are you currently taking any medicines for your mental illness? *
Do you need to see a counselor or psychiatrist for medication monitoring? *
Do you have health care coverage? *
What type of health care coverage do you have? *
Have you ever used any of the following: *
Have you ever been in treatment (in or out patient) for substance abuse?
Are you required to register as a sex offender or violent offender to youth? *

 

Our Office

680 Genesee St.
Waukegan, IL, 60085