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retreat video
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Program Enrollment Form
Home
Vision
Mission
Board of Directors
About Us
Profile Summary
Our Services
Our Projects
Contact Us
Donations
Videos & Blogs
DR J Crisis Shelter
DR J Transitional Shelter
Application Form
Complaints
Extension Requests
Dr J Rising Star Retreat
retreat video
Retreat Flyer
Flight Information
Program Enrollment Form
0. Choose Shelter
a. Shelter (DJF)
b. Shelter (Private)
c. Shelter (Hirps)
1.Name
2. Gender
Male
Female
Other
3. Date Of Birth (select day and Month ..change year manually)
4. Address (Damaged)
5. Lodging Request Duration (Estimation)
7. Insurance on Damaged Home/Apt
Insured
Not Insured
Delinquent Insured
Not Sure
Other (List in Details)
8. Damaged Living Address Type
Owned Home
Bank Owned Home (mortgage)
Leased Property Home
Rented Home/Apartment
Other (list in details)
9. Contact Nr.
10. E-mail
11. Marital Status
Single
Married
Divorced
Partner With Children
Partner (No Children)
12. Household Capacity For Lodging
1 Person
2 Persons
3 Persons
4 Persons
5 Persons
6 Persons
7 Persons
8 Persons
9 Persons
10 Persons
More Than 10
13. Relation and Age of Co-Lodgers
14. Place of Birth
15. Resident Status
Dutch Citizen
Has Resident Permit
Unregistered Citizen
Other (See List in Details)
16. Employment Status
None (Not Employed)
Employed
Self Employed
Pensioneer
Other ( specify in details section)
17. Employer (Company)
18. Department / Section
19. Job Title / Occupation
20. Medical Conditions
None
Diabetese
High Blood Pressure
Heart Problems
Paralyzed
Impaired Vision
Other (Specify in details box)
21. Medical Insurance
None
SZV
Nagico
Ennia
Fatum
Capital Life Insurance
Sagico
Other (Specify in details section)
22. Addictions
None
Cocaine
LSD
Heroine
Marijuana
Alcohol
Tobacco
Cigarettes
Coffee
Other (fill in by details)
23. Details
24. Picture of Passport/ID/Drivers License
25. Picture of Damaged Home or Apt (optional)