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Starfish Program Application
Please complete all the questions to the best of your ability.  Use additional paper if necessary.  Please PRINT LEGIBLY!

Applicant name:_______________________________________

Address:_________________________________________________

Are you planning to move? If yes, when/where?________________

_____________________________________­­____________________

Best phone number to reach you:_____________________________

Email address:____________________________________________

Applicant birthdate:______________________

Number of children and ages:__________________________________

__________________________________________________________

Indicate which children live with you:_____________________________

Other adults in your household:__________________________________

Monthly Income:____________________  Source:__________________

If you are currently employed please list place of employment:______________

Do you have an open OFP for you or against you?  If yes, please describe:

 

 

 

What legal issues do you need to take care of?  (example, get license back, pay court fees, child custody etc.):________________________________________

________________________________________________________________

________________________________________________________________

Are you ready and willing to be held accountable and to move forward in your life?____________________________________________________________

What are your short term goals?______________________________________

________________________________________________________________

How did you hear about the Starfish Program?  If referred, please list name and title of person who referred you:_________________________________

________________________________________________________________

Describe the things you would most like to change in your life and/or the way you feel about yourself?______________________________________________

__________________________________________________________________

Are you willing to commit to the 18 month program, and do the homework and the work necessary to change your life?  ________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Share anything else you would like known:___________________________________________________________

__________________________________________________________________

 

Applicant Signature:_______________________________________

Date:___________________________________________________

 

Please send completed application to Cara Ruff, Starfish Program, 215 North Benton Drive, Sauk Rapids, MN 56379 or email it to carar@independentlifestyles.org

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