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STAY Program

Supporting Transitional Age Youth

Application Form

URL
This field is for validation purposes and should be left unchanged.
Name
Application Date:
Birthdate
SSN
Requested Date for Residency
Present Address
Phone #
How long at this address?
Identification Number
Have you lived in Santa Cruz County before?
When was the last time?
For how long?
Emergency Contact Name
Relationship
Phone #
Do you have your original Birth Certificate?
Do you have your original Social Security Card?
I am or have been in
- Foster care
- Probation
- Legal guardianship
Name of last social worker or probation officer
Email Address
Demographic Information
Gender
- Male
- Female
- Other
Primary Language
- English
- Spanish
LGBTQ
- Yes
- No
Hispanic or Latino?
- Yes
- No
- Physical Disability
Race (select all that apply)
- American Indian or Alaska Native
- Asian
- Black or African American
- Pacific Islander or Native Hawaiian
- White
Special Needs
- Alcohol Abuse
- Developmental Disability
- Domestic Violence
- Drug Abuse
- HIV/AIDS
- Mental Illness
Employment/Education Information
Are you currently employed?
- Yes
- No
If yes, part-time or full-time
If yes, Where?
Start date
Are you currently enrolled in an educational program?
- Yes
- No
If yes, Where?
Start date
Health and Medical Information
Physical Health:
- Good
- Fair
- Poor
Please list all currently prescribed medications
Are you currently under the care of a medical provider?
- Yes
- No
If yes, what is the name of your provider?
What is the address and phone number of your provider?
Do you currently or have you in the past seen a psychiatrist?
- Yes
- No
If yes, what is the name of your provider?
What is the address and phone number of your provider?
Legal Information
Have you ever been arrested? (If yes, please answer below)
- Yes
- No
Date
Offense
Briefly describe incident
Are you currently on probation?
- Yes
- No
Do you have any current charges pending?
- Yes
- No
If yes, what charges
Family and Social Support
What type of support do you have from outside resources?
Tell Us More
What are your current goals?
What do you hope to gain from placement at STAY?
What are some of your strengths?
What are some areas you are struggling with?