Euthus House Application
Euthus Ministries - 1201 W Patricia Ave. #2, Wasilla, AK 99654 Office (907)795-9268 info@euthushouse.org
Date of Application: Date Expected Release Date: Date
Mandatory Release Date: Date
Full Legal Name: Client first nameClient middle nameClient last name
PO Name:Probation
Do you go by any other names than what is on your birth certificate? Checkboxes
Please list these names, including all aliases: Text field
Date of birth: Client birthdate OBSIS # Text field
Do you have your Social Security Card? Checkboxes
Photo ID? Checkboxes
Birth Certificate? Checkboxes
Do you have an AK ID or Driver's license? Checkboxes If Current, ID/Drivers License# Text field
Current Phone # Client phone
Current address (if prison, please list prison address)
Client Address
Contact person who can be reached and will always know of your whereabouts? Contact
Family information:
Family Members
Marital status:
Client marital status
Other than a spouse, do you have a relationship with anyone of the opposite sex at this time? Checkboxes
Full Legal Name: Text field
Please describe the nature of the relationship: Text field
Military History:
Are you a veteran of the United States military? Client veteran status
In which branch of the service did you serve? Text field
What were your dates of service? Text field
Finances:
List all forms of income you presently receive (DOC, pensions, disability, social security, welfare, etc.)
Paragraph
Do you currently have your own checking account? Checkboxes Saving account? Checkboxes
The monthly rent per resident is $750 Initials Initials Text field
Have you applied to Second Chance or Mat-Su Reentry? Checkboxes (If not, apply before release) Accepted? Checkboxes
Do you owe child support? Checkboxes How much? Text field
What do you owe for costs and fines? Text field
Do you owe restitution? Checkboxes How much? Text field
Do you have substantial debts ($1000.00 or more)? If yes, to whom do you owe these debts? Be sure to include credit cards, collection agencies, bad checks, etc.
Paragraph
Religious Affiliation:
Checkboxes
Home Church: Text field
Education:
EducationHistory
Do you have any plans of attending school in the future? Text field
Medical:
Client health problems
Are you physically and mentally able to work full-time? Checkboxes
Are you declared disabled by a doctor? Checkboxes Please list your disability: Text field
Medications:
Medication
Have you been diagnosed with a psychiatric or mental disorder? Checkboxes
Client diagnosis
Vehicle Information:
Do you have a vehicle? Checkboxes If so, list vehicle information:
Make and year of vehicle: Text field Color of vehicle: Text field
License plate number: Text field
Current legal minimum amount of auto insurance? Checkboxes
List insurance company, agent, phone number and policy number.
Paragraph
Criminal History:
Please answer the questions in this section fully and honestly:
Criminal History
Do you have any open charges in Alaska or any state? Checkboxes If yes, please list: Text field
State of charge? Text field
Have you ever been charged with a sexual crime? Checkboxes
Do you have any outstanding warrants? Checkboxes
If yes, please list: Text field
State warrant is issued in? Text field
How many times have you been in prison? Text field
Charge Text field
State Text field Date of arrest Text field Date of release Text field Currently serving or previously served? Text field
Charge Text field
State Text field Date of arrest Text field Date of release Text field Currently serving or previously served? Text field
Charge Text field
State Text field Date of arrest Text field Date of release Text field Currently serving or previously served? Text field
Charge Text field
State Text field Date of arrest Text field Date of release Text field Currently serving or previously served? Text field
Do you have any infractions while in prison? Checkboxes If yes, how many? Text field
Infraction Text field
Date Text field
Infraction Text field
Date Text field
Infraction Text field
Date Text field
Infraction Text field
Date Text field
What programs have you been involved in during incarceration and which ones did you complete? (please list all you can)
Program Text field
Dates in Program Text field
Program Complete Checkboxes
Program Text field
Dates in Program Text field
Program Complete Checkboxes
Program Text field
Dates in Program Text field
Program Complete Checkboxes
Program Text field
Dates in Program Text field
Program Complete Checkboxes
Program Text field
Dates in Program Text field
Program Complete Checkboxes
Will you be on Electronic Monitoring? Checkboxes
Substance Abuse:
Do you have a history of substance abuse? Checkboxes
Client substances of choice
Last date you used any substance: Text field
Why do you want to live in this Home? (check all that best apply to you) Checkboxes
Other (Please explain) Paragraph
What needs to change in your life so you do not go back to prison? (You may check MORE than one) Checkboxes
Other (Please explain Paragraph
Employment History:
Please list all past employers including jobs while incarcerated.
EmploymentHistory
What goals do you have for future employment? Paragraph
What wages are you willing to accept to start a new job? Text field
Are you a resident of Alaska? Checkboxes If no, what is your state of residence? Text field
If you are not a resident of Alaska, do you wish to return to another state? Checkboxes
Your Story:
**Please use the next section to tell us:
Who are you? Tell us about yourself and the story of your life, good and bad home life, parents, etc.?
What led you to prison, to addiction, and/or to violence? Tell us about how you came to faith in Jesus,
what difference He has made in your life, and your life in Him today.
Why do you want to come to the Euthus House?
Paragraph
**Please read the resident handbook before signing this document:
Euthus House Resident Manual
I Text field (print name) have read the Euthus House Resident Manual and if accepted agree to abide by the guidelines and rules therein.
Resident signature: Signature