Dummy Event Page | Pay It Forward SA

First name

Last name

Phone Number

Date of Birth

Month

Day

Year

Age Range

Gender

Race

Ethnicity

Are you a US Military Veteran?

What is your highest level of education?

Have you experience domestic violence in the last 12 months?

Are you currently experiencing homelessness or at risk of homelessness?

Select your recovery program:

What is your current recovery step? If you answered "Other" above, please explain here.

What is the name of your sponsor?

What is your sponsor's phone number?

Please select your sober home:

If you answered "Other" above, please provide the NAME, ADDRESS, and PHONE NUMBER of the home.

What day did you move-in to your current sober home?

Month

Day

Year

Have you received funding from Pay It Forward SA in the past? If so, please list date(s) and amount(s).

Please list ALL previous sober living home(s) and ALL outstanding balance(s). NOT including present home.

What is the balance owed at current sober home?

What is the amount already paid to current sober home?

Length of time clean & sober (# of days)

What is your sobriety clean date?

Month

Day

Year

What is your most recent treatment center?

Who is your current employer?

How many hours do you work per week?

What is your current monthly income?

Are you on disability or unemployment?

If you answered "yes" above, what is the monthly amount?

How long have you been at your job or on disability/unemployed?

What is your reason for applying for Bridge Move-In Assistance?

Follow-up surveys allow us to gather information that allows u to secure funding for the next person in need. If approved for funding, do you agree to participate in all follow-up surveys?

Check any items that you would like to request assistance with:

By clicking "Yes" below, I acknowledge that I have provided complete and honest answers to all questions. I understand that Pay It Forward SA does NOT provide updates on application status and that repeated attempts to inquire as to the status of an application will result in that application being moved to the bottom of the waiting list and possibly denied.

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