sara’s Online Application Please review our Community Standards before submitting application. Community Standards Name * First Name Last Name Date of Birth * MM DD YYYY Age * Phone * (###) ### #### Email * Marital Status Do you have a picture ID? * Yes No How did you hear about Sara's House? * Requested move in date * MM DD YYYY Do you commit to the full year program? * Yes No Employer * Job Title * Do you currently smoke or use any tobacco products? * Yes No Are you a registered sex offender? * Yes No Are you on parole, probation, waiting to be sentenced, awaiting a hearing/trial? * Yes No If yes, please explain Parole Officer's Name First Name Last Name Parole Officer's Phone # (###) ### #### Have you had any mental health diagnosis in your lifetime? Yes No If yes, please list: Are you on any medications? * Yes No If yes, please list the names of medications and purposes: What is your motivation for applying to Sara's House? * Do you understand and agree to the Community Standards? * Yes No Do you understand and agree to fulfill all program requirements, including attending the required number of classes, working with a mentor and attending church services? * Yes No Fees ●A non-refundable Intake and Administration fee of $300 and the Weekly program fee for the first week of $125 is required prior to entry to the program. ●The weekly program fee of $125 is due each week on Monday. A $5 late fee will be charged for each day past due. ● The program fee is to be paid by card or money order. ● Following 10 days of failure to pay program fees will result in the resident being asked to leave the program. Grants and limited scholarships are available to those who qualify. Please type your name below as an "electronic signature" * Thank you for your application! Please allow 3-5 business days for a call back from our intake coordinators.
