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FAILSAFE-ERA RIGHT ROAD REENTRY
(COURAGE TO CHANGE)

Getting Started with Courage to Change is a five week program that meets on every Tuesday evening at 7pm at

125 Olde Greenwich, Suite 100, Fredericksburg, VA. 

If you have additional questions, please contact the office at (540) 479-3021,

Right Road Reentry Courage to Change Application

Date of Application
Month
Day
Year
What are Your Needs?

Full Legal Name

Multi-line address
Gender
Male
Female
Race
White
Hispanic
Black
Asian
Native American
Pacific Islander
Are you a citizen of the United States?
Yes
No
If No, are you authorized to work in the United States?
Yes
No
Do you have any pending court cases?
Yes
No
Do you have any pending court cases?
Yes
No
Are you currently on probabation?
Yes
No

Education

High School Diploma/GED
Yes
No
College Graduate
Yes
No
Specialized Training or Certificate
Yes
No

Transportation

Do You have a valid Virginia drivers license?
Yes
No
Do you have available transportation?
Yes
No

Most Recent Employer

Military Service if Applicable

Emergency Contact Info

Request a Time Slot to meet a Case Manager

Options are Tuesdays, 10am or 5:30pm

Thursdays 10am, 11am, and Noon

We will confirm your appointment as soon as we receive this application.

Disclaimer and Signature

The first step (this application) in the screening and reviewing process of this program is to ensure that prospects are dedicated, willing, and able to commit themselves to participate in the program to become successful in the community and in the workplace. More importantly, FailSafe-ERA's goal is to ensure that all candidates possess the attitude, honesty and characteristics necessary to exceed the expectations of any future employer. I certify that my answers are true and complete to the best of my knowledge.

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