Apply - Open Arms Village

First Name

Middle Name

Last Name

Sex

Date of Birth

Age

Driver's License Number

State

Phone

Are you a U.S. Citizen?

Yes No

Are you able to read/write English well?

Yes No

Where did you stay last night?

Release date for those in an Institution/ARC

How long have you been homeless?

Have you ever been baker acted? When?

How long have you been in Marion County?

Where is your nearest family?

Why are you homeless?

Write a few sentences about what brings you here/what happened.

Write a few sentences about what brings you here/what happened?

Employment Status

If you are not currently employed, what was the last position held?

Why did you leave your last position?

Date of last position held

Start Date

End Date

If not employed, are you currently looking for work:

Yes No

If no, explain why:

Why did you leave your last position?

Are you a Veteran?

Yes No

Did you serve in a war zone?

Yes No

Are you currently in the military?

Yes No

List your service dates

Service Area:

Service Area

Which military branch did you serve?

What type of discharge did you receive?

Are you disabled?

Yes No

Have you been disabled for more than a year?

Yes No

Check all disabilities that apply:

Substance abuse history:

Substance abuse history

When is the last time you used drugs or alcohol?

Would you pass a drug screen and breathalyzer?

Yes No

Are you currently taking Buprenorphine (Suboxone) even if prescribed?

Yes No

Have you ever been convicted of a felony?

Yes No

Have you ever been convicted of a sex crime?

Yes No

Have you served time in jail or prison?

Yes No

If yes, how long:

Do you have any pending legal matters?

Yes No

Are you currently on probation?

Yes No

If yes, what is the date your probation expires:

Do you have legal fees/fines that you currently owe?

Yes No

How would you rate your general health right now?

Do you have a regular doctor?

Yes No

Are you currently taking any medications?

Yes No

If so, list all medications that you are currently taking:

Is there medication that you are supposed to be taking but do not have it?

Do you have a psychiatric diagnosis?

Yes No

Do you have any known allergies?

Yes No

If so, what?

Do you currently use alcohol?

Yes No

Do you currently use drugs?

Yes No

Do you have a history of alcohol or substance abuse?

Yes No

Have you ever received treatment for a mental health issue?

Yes No

When is the last time you had a dental appointment/check-up?

Are you currently fleeing abuse?

Yes No

Have you ever been a victim of domestic violence?

Yes No

First Name

Middle Name

Last Name

Sex

Date of Birth

Race

Ethnicity

Driver's License Number

Driver's License State

Social Security Number

If you have had a name change, or used other names and/or nicknames in the past?

Open Arms Village at St. Mark’s United Methodist Church
Autherization for Background Check

Acceptance

I hereby authorize Open Arms Village to check any and all records pertaining to criminal convictions and for any law enforcement agency to release to Open Arms Village information regarding convictions under Florida State Statutes or Statutes from other jurisdictions.

Program Application

1839 NE 8th Road
Ocala, FL 34470

(352) 304-6229

oav.director@gmail.com

Program Application

1839 NE 8th RoadOcala, FL 34470

(352) 304-6229

oav.director@gmail.com

1839 NE 8th Road
Ocala, FL 34470