Application – Kylee Ko Foundation, Inc.

Name:

Height:

Weight:

Date of Birth:

Current Age:

Phone Number:

Email:

Sexual Orientation:

Marital Status:

Children/Age:

Do you pay/owe child support:

Social Security Number:

Driver License:

Is your driver license valid?

Are you able to work:

If your answer is no, why not?

Current Employment:

Job Title:

Approximate Monthly Income:

High School Diploma:

College Education:

Special Training / Certificates:

Do you have a current resume?

Current Health Insurance:

Approximate date of last check up or physical:

Have you ever attempted suicide?

Recovery Program You Completed:

Dates started:

Date finished:

Did you finish the program?

If you didn't finish the program, why not?

How long have you been sober?

What was your drug of choice?

Do you smoke or chew?

Current Medication:

Any previous gang affiliation:

Any current gang affiliation:

Closest relative/emergency contact name:

Phone Number:

Location:

Convicted of felony or misdemeanor:

Currently on parole or probation:

If yes, name and phone number of officer:

How often do you report:

Do you owe any court fees?

Please check any of the following diseases you have had:

Religious beliefs:

Church you attend:

Have you ever been water-baptized?

What are you hoping to get out of being a resident at the Kylee Ko House?

Check what you need help with:

Interested in coming to the Kylee Ko House?
Please complete the application below and our staff will get back to you as soon as possible

address

Kylee Ko Foundation Inc

working hours

Interested in coming to the Kylee Ko House? Please complete the application below and our staff will get back to you as soon as possible

address

Kylee Ko Foundation Inc

working hours

Interested in coming to the Kylee Ko House?
Please complete the application below and our staff will get back to you as soon as possible