Name *

First Name

Last Name

Preferred Name

First Name

Last Name

Phone

(###)

###

####

How did you hear about Deep Time?

(###)

###

####

Birth Date

MM

DD

YYYY

Are you comfortable with a Christian based workplace?

Yes

No

Can you stand and move for extended periods (Up to 8 hours) with standard breaks?

Yes

No

Can you life and carry up to 30 lbs with or without reasonable accommodation?

Yes

No

Do you have any barriers to reading, writing, and/or educational attainment?

Yes

No

Are you willing and able to follow food-safety and cleanliness procedures INCLUDING attainment of mandatory food-safety training?

Yes

No

Do you currently have the following? (Check all that apply)

Government Photo ID

Birth Certificate

Social Security Card

State ID

Work Permit

Tribal ID

Current Housing Situation

Rental

Home Ownership

Staying With a Friend or Family Member

Shelter

Sober-living

Transitional Housing

Hotel or Motel

Unsheltered (Outside or Vehicle)

Other

Primary Transportation

Personal Vehicle

Rideshare

Bus

Bike

Walk

Other

What does your current phone access look like?

Personal Phone

Borrowed Phone

None/Other

Do you have a primary care provider?

Yes

No

Behavioral Health Support (Check All That Apply)

Counseling/Therapy

Peer Support

Recovery Meetings

Case Management

Psychiatric Care

None Currently

Do you understand that at least 2 forms of behavioral health support are required for participation as a Sojourner?

Yes

No

Are you currently in recovery?

Yes

No

Are you currently engaged in MAT (Buprenorphine/Suboxone®, methadone, naltrexone/Vivitrol®, etc.?)

Yes

No

Do you understand that random drug tests are administered to each Sojourner at Deep Time?

Yes

No

Have you ever been incarcerated?

Yes

No

If you answered "yes" to the previous question, check all that apply:

Jail

Prison

Juvenile Justice

What is your current justice involvement? (Check all that apply)

Probation

Parole

Pre-trial

Drug Court

Diversion

Parent/Immediate Loved One Currently Incarcerated

Other

Are you interested in applying for any of the following:

SNAP

Medicaid

WIC

Childcare Subsidy