Complete Your Registration Form Online

Highest Level of Education Completed

Some high school High school diploma/GED Some college College degree/postgraduate

Have you served in the US Military?

Yes No

Marital Status

Single Married Divorced Separated

Do you have children?

Yes No

Are you receiving SNAP benefits

Yes No

Are you receiving DTA benefits

Yes No

Are you receiving SSI benefits?

Yes No

Are you receiving SSDI benefits?

Yes No

Are you receiving cash benefits?

Yes No

Level of incarceration (if more than one, please answer for your most recent period of incarceration)

Federal State Other

State of incarceration (if more than one, please asnwer for your most recent period of incarceration)

Start date of incarceration (if more than one, please answer for your most recent period of incarceration)

End date of incarceration (if more than one, please answer for your most recent period of incarceration)

Are you currently under probation or parole?

Yes No

Are you receiving case management services?

Yes No

What services can we help you with?

I understand that the Healing Our Land Inc will use this information to assess, evaluate, and assist mewith all issues related to my reentry services and needs.

Yes, I understand

I further give permission to all staff of the Healing Our Land Inc to store and record information Iprovide on to a case management software, for the purposes of demonstrating the needs of returningcitizens and to inform my case management services.

Yes, I give permission

I understand that any information I share with the Healing Our Land Inc, is subject to disclosure underthe Public Records Law, G.L. c. 66, Sec. 10.

Yes, I understand

I understand that the information I have provided will be used to contact me OR the person identified inthe Registration Form.

Yes, I understand

I understand I can terminate my engagement with HOLI at any time

Yes, I understand

Optional Demographic Information The Healing Our Land Inc uses this data only for analysis and reporting purposes. Filling it out helps usunderstand who we are reaching and how to better reach different communities. Sharing, or not sharing, thisinformation is optional.Gender Identity

Hispanic Latino Non-Hispanic/Latino Prefer not to say Unsure

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