Have you been in Foster Care? No Yes * If please explain:   ‘Yes’, EDUCATION HISTORY Please give names and dates of the last two schools you have attended. Name of school From: To: Have you completed your High School level education? No Yes If do you have a: GED H.S. Diploma     ‘Yes’, If please complete the following section: ‘No’, Are you currently attending school? No Yes   If name of school: Current Grade: ‘Yes’, If do you plan to finish school? No Yes If do you want a: GED H.S. Diploma     ‘No’, ‘Yes’, What was the highest grade you completed? Date of last attendance: MEDICAL HISTORY Please list any medications you are taking. Have you ever been hospitalized for psychiatric reasons? No Yes   If please give names and dates of hospitalization. ‘Yes’, Name of hospital From: To: Have you ever been in drug treatment? No Yes If please give names and dates of treatment program.   ‘Yes’, Name of program From: To: EMPLOYMENT HISTORY Please list any jobs you’ve held, or job training programs you’ve been in. Employment/Job training program: From: To: Reason for leaving: Are you currently employed? No Yes   If How long? ‘Yes’, Please answer the following:
Have you been in Foster Care?  No  Yes * If ‘Yes’, please explain: EDUCATION HISTORY Please give names and dates of the last two schools you have attended. Name of school From: To: Have you completed your High School level education?  No  Yes If ‘Yes’, do you have a:  GED  H.S. Diploma If ‘No’, please complete the following section: Are you currently attending school?  No  Yes If ‘Yes’, name of school: Current Grade: If ‘No’, do you plan to finish school?  No  Yes If ‘Yes’, do you want a:  GED  H.S. Diploma What was the highest grade you completed? Date of last attendance: MEDICAL HISTORY Please list any medications you are taking. Have you ever been hospitalized for psychiatric reasons?  No  Yes If ‘Yes’, please give names and dates of hospitalization. Name of hospital From: To: Have you ever been in drug treatment?  No  Yes If ‘Yes’, please give names and dates of treatment program. Name of program From: To: EMPLOYMENT HISTORY Please list any jobs you’ve held, or job training programs you’ve been in. Employment/Job training program: From: To: Reason for leaving: Are you currently employed?  No  Yes If ‘Yes’, How long? Please answer the following:
Stopover-TLP-Application.docx