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4-H Archery Club

4H Archery Club Meeting

Taking place in Building C

5:30pm - 9:00pm

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Monthly Report

Any personal information you disclose will remain confidential.

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Month *

Year *

First Name *

Last Name *

Are you currently houseless? *

Yes

No

If yes, for how long? *

Address *

City *

State *

Zip *

Mailing Address (if different)

Mailing Address (if different from Address)

Mailing City

Mailing State

Mailing Zip

Others in Residence

Home Phone

Please enter a number we can at least leave a message at. This is important for us to contact you!

Cell/Other

Email *

Make/Model of Vehicle you drive

License Plate Number

Color

Valid License

Yes

No

Employment / Education / Financial

Employer/School *

Hours *

Other Financial Support (TANF, SSI, WIC, etc.)

Monthly Income * $

Employment Change *

Yes

No

Treatment

Other *

Please explain what treatment you are required to attend

Date of last appointment

Date of next appointment

Completion date

Substance Use

In the last 30 days, have you felt a strong urge to drink alcohol or use drugs? *

Yes

No

In the last 30 days, has alcohol/drugs hindered your ability to move forward in life? *

Yes

No

If you are in treatment, what do you feel you are gaining from it?

Case Plan

My goal/focus is (i.e. employment, treatment, insurance, sobriety, etc.) *

What have you done in the last 30 days to work towards your goals? *

Law Enforcement Contact

Have you had police contact since your last report? *

Yes

No

Date(s) *

If yes, please explain *

Is there anything you would like to discuss with your PO?

Signature *

By signing below I acknowledge that the statements I have made on this form are true, correct and completed to the best of my knowledge

Signature Date *

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Directions

Polk County Courthouse Main Conference Room

850 Main St First Floor

Dallas, OR 97338

See map: Google Maps

Oregon

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