M-A-D After Jail/Prison Ministry Online Application

EIN: 41-2195871

http://00madm.wix.com/prison-ministry#!online-store/cj9w/

 

At this time, this form does not allow you to save and return to it later.  What this means to you is that you will need to complete the form in one sitting.

 

Click on and/or copy & paste this following link to give the required $175.00 donation/gift online now.

 http://www.makingadifferenceministry.myevent.com

 

1. Your Name:__________________________________________________________________________________

 

 

2. Your Address 1:________________________________________________________________________________

 

3. Your Address 2:________________________________________________________________________________

 

4. Your City:_____________________________________________________________________________________

 

 

5. Your State:____________________________________________________________________________________

 

6. Your Zip:______________________________________________________________________________________

 

7. Your Phone:___________________________________________________________________________________

 

8. Your Email:____________________________________________________________________________________

 

 

9. Name of Person Incarcerated:____________________________________________________________________

 

10.  Jail / Prison ID#:______________________________________________________________________________

 

11.  Facility Name:________________________________________________________________________________

 

12.  Facility Address 1:____________________________________________________________________________

 

13.  Facility Address 2:___________________________________________________________________________

 

14.  Facility City:_________________________________________________________________________________

 

15.  Facility State:_________________________________________________________________________________

 

16.  Facility Zip:_________________________________________________________________________________

 

Please check any of the following that apply: 

 

17.  Sex Crime:____ Crime Involving Children (Minors):____ Violent Crime ____

 

18. Current length of incarceration?_______________

 

19.  If this is not your/their first incarceration, how many years have you/they been incarcerated throughout your/their life?_____________

 

20.  In order of preferences, please list where your loved one would prefer to live after they are released.

 

21.  After your/their release, will you/they have in your/their possession the necessary identification for you/them to go to work? 

Yes___ No___

 

22.  Please check each item you/they will need to obtain: Certified birth certificate?___ Social Security Card?___ State Issued Drivers License or Photo ID?___

 

23.  Please list the types of employment the ex-offender has held in the past, any known skills or trades that give some indication as to your/their ability to find work after you/they are released:________________________________________________________________________________________________________________________________________________________________________________________________________________

 

24.  Please list any known health conditions (e.g. diabetes) and required medications (e.g. Metformin):_______________________________________________________________________________________________________________________________________________________________________________________________________________

 

25.  Please list any known mental health conditions (e.g. depression) and required medications (e.g.Prozac):____________________________________________________________________________________________________________________________________________________________________________________________________________

 

26.  Before your/their incarceration were you/they receiving SSI disability income? 

YES____ NO____ 

 

27.  If so, how much? $__________

 

28.  If known was the reason for the disability... PHYSICAL or MENTAL or BOTH?___________ 

 

29.  Are you/they a professing Christian? YES____ NO____ 

 

30.  Would you/your loved one like for us to try to locate a church that is willing to try to provide support, mentoring and accountability after they are released? (Please note: it is important that this is your/their desire and not just yours for them.) YES____ NO____ 

 

31.  If any, what is your/their church background/denomination (e.g. Catholic, Baptist, Pentecostal, etc.)?___________________________

 

32.  If you/they have the contact information for any church or minister that you/they know has had an impact in your/their life, whether past or present, please provide it below.

________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

33.  Are you/they seeking housing only--just a place to stay until you/they get on their feet--OR would you/they prefer a faith-based, structured environment, which no doubt will have rules and require certain faith-based instruction? 

HOUSING ONLY____ FAITH-BASED HOUSING_____ 

 

34.  How much regular, monthly, financial support will be available to you/them (from any and all sources including you/them, friends, family, church, organization or government agency)? Less than $100.00____ Less Than $500.00____ Less Than $1,000.00____

More Than $1000.00_____

 

35.  Is there a provider providing additional financial support if you/they could be certain the funds were going to an organization for your/their assistance to you/them and not directly to you/them? YES____ NO____

 

36.  Help us prevent SPAM. How much is three + two? (Enter your answer as a number.) _____

*

37.  Please provide the names, email addresses, phone numbers and addresses of anyone you/they believe who may be interested in providing assistance to you/them after they are released. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________