Nonviolence Education Group Intake Paperwork Step 1 of 3 33% Name First Middle Last Date of Birth MM slash DD slash YYYY Gender Male Female Current AgeEmail Cell PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Emergency Contact InformationEmergency Contact Name First Last Emergency Contact PhoneEmergency Contact RelationshipPersonal InformationCurrently Employed? Yes No EmployerWork PhoneEducation8th grade or lesssome high schoolhigh school graduateGEDsome college4-year degreegraduate degreebeyond graduate degreeselect highest level completedEthnicity/Race African-American Asian Hispanic/Latino Indian/Native American Pacific Islanders Caucasian/White Unknown Other Primary LanguageMilitary Service Yes No Branch and Years ServedMarital StatusNever MarriedMarriedWidowedSeparatedDivorcedNumber of people living in your householdFamily Type 2 Adults/No Children 2 Parent Household Foster Single Person Single Parent Other Are you currently staying in a shelter? Yes No Are you currently homeless? Yes No Course DetailsReason for Attending Court Ordered/Probation DCS Referral Self-Referral Please Note: Online courses are only available to persons located more than 20 miles from our Kokomo location or with prior approval.What format of course delivery are you interested in attending? Online In person Victim Details and ConsentPlease include the listed victim’s name and contact information. If unknown, the name and city information is sufficient. If you only have one victim, please leave the other fields blank.Victim's Names Add RemovePlease click the plus sign to right to add others.Please tick the boxes below to confirm that you have read all the program information and agree to adhere to the established policies and procedures.Rules, Requirements and Expectations(Required) I have reviewed and understand the Rules, Requirements and Expectations for ParticipantsProgram Termination(Required) I agree to abide by these rules, requirements and expectations and I understand that my failure to do so could result in my termination from the program.AIP permission(Required) I consent to giving the AIP permission to make reports, to disclose participant file information and to communicate as neededVictim Confirmation(Required) I have listed all information about my victim(s) to the best of my knowledge.
