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San Quentin Rehabilitation Center Reentry Fair
Saturday, September 28, 2024
Registration Form
The deadline to submit this application is Monday, June 17, 2024.
Name of the person completing this application:
*
Contact Phone Number:
*
Email contact:
*
Please confirm your email
*
Please provide the following information:
RECORD CLEARANCE:
PLEASE SPEICFY THE FOLLOWING INFORMATION AS IT APPEARS IN YOUR I.D.
Can your organization write support letters for people going to the Parole Board for release consideration?
*
Yes
No
Please specify Resource Fair Exhibitor's Information:
Government Agency, Non-Profit Organization, or Employer name
*
Organization Website:
*
Organization Street Address
*
City
*
State
*
Postal Code
*
Name of the Primary Person Attending this Conference
*
Title or Position of the Primary Person Attending this conference
*
Contact Phone Number:
*
Email contact:
*
Please confirm your email
*
RECORD CLEARANCE:
PRIMARY'S CONTACT INFORMATION OF THE PERSON ATTENDING THIS CONFERENCE AS IT APPEARS IN YOUR I.D.
First Name:
*
Middle Name:
Last Name:
*
Driver's License or State I.D. #:
*
EXP.
*
DOB:
*
SECONDARY'S CONTACT INFORMATION OF THE PERSON ATTENDING THIS CONFERENCE AS IT APPEARS IN YOUR I.D.
Please provide information about the person who will substitute you in case you are not able to attend this event.
Name of the Secondary Person Attending this Conference
Title or Position of the Second Person Attending this conference
Contact Phone Number:
Email contact:
Please confirm your email
RECORD CLEARANCE:
First Name:
Middle Name:
Last Name
Driver's License or State I.D. #:
EXP.
DOB:
Please provide information about the person who will substitute you in case you are not able to attend this event.
PLEASE TELL US MORE INFORMATION ABOUT YOUR ORGANIZATION
Please specify categories of services your organization provides:
*
Employment Services
Vocational training, education, and scholarships
Housing Services
Health and Treatment Services
Legal Services
Faith / Church Organization
Family and Children
Transportation
Mentorship
Basic Necessities / Clothing, Etc.
Tattoo Removal
Other
Other
Regions your organization provides services:
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Northern California
San Francisco Bay Area
Central California
Southern California
Other
Other
Does your client need to be on probation or Post Release Community Supervision (PRCS)
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Yes
No
Does your client need to be on parole?
*
Yes
No
General age groups your organizations support:
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Children of Incarcerate (0-18)
TAY Youth (ages 18-24)
Adults (25-55)
Seniors (age 55+)
All ages
Special populations your organization supports::
*
Women
Men
LGBTQQ+
Foster Care
HIV+
Homeless
Disabled
Veterans
Mental health needs
Parents
Immigrants
Crime Survivors
Program open to all populations
Behavioral Health & SUD Treatment
Learning disabilities or illiteracy
Description of services or products you offer to formerly incarcerated individuals to support their post release needs:
*
Description of services or products you offer to crime survivors to support their healing:
*
I identified myself as:
*
A formerly incarcerated person
A family member with a loved one incarcerated
A crime survivor
None of the above
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