TAY Application

Please complete the questions in this application to the best of your ability. The questions are designed to help us understand and assess your current situation. If you would prefer to print the application and send it via mail or fax, a PDF copy is available here.

To which program are you applying? *

Multiple or Unsure

THPP (16-18yrs)

THP+FC (18-21yrs)

PATH-Plus (18-21 emancipated)

First Name *

Last Name *

Nickname

Email *

Phone *

Emergency Phone Number *

Street Address *

City *

Zip Code *

County of Origin: *

Are You Emancipated? *

Date of Birth *

Social Security Number (SSN)

Name of Current/Last Social Worker *

Phone Number of Current/Last Social Worker *

Name of Current/Last Probation Officer *

Phone Number of Current/Last Probation Officer

Do you have children? *

If so, How Many?

What are the Ages of Your Children?

Are You Pregnant? *

If Yes, When is Your Due Date?

A Female is Pregnant With My Baby *

Are You Currently Employed? *

If Yes, Where?

Are You Currently Enrolled in School? *

If Yes, Where?

Are You Now or Have You Ever Been on Probation? *

If Yes, Please Explain

Have You Previously Participated in any California THPP, THP+FC or THP+ Program? *

If Yes, Explain why You Left the Program

Please list up to three adult references:

Reference #1

Name: *

Relationship *

Address *

Phone *

Reference #2

Name:

Relationship

Address

Phone

Reference #3

Name:

Relationship

Address

Phone

Please Paste Reference Letter Text Here

Please List 3 Goals You Currently Have for Yourself.

Goal 1 *

Goal 2 *

Goal 3 *

How Do You Think this Program Can Help You? *