Liberty Restoration Community Development Center

	Liberty Restoration Employment Training and Job Placement Services 12415 Wardline Road ~ Hammond, LA 70401 Phone: (985) 340-7034 ~ FAX: (985) 340-7035
Restoring lives & building better communities, one person at a time…” APPLICANT DATA SHEET

Participant Name:

SSN:	Gender: Male Female
Birthday:
Home Address: County/Parish:	City: State: Zip
Mailing Address:	City: State: Zip
Primary Phone:	Secondary Phone:
Email Address :

DISABILITIES
Referral Source:
Primary Impairment: Please check all that apply
Alcohol Dependence Drug Dependence Physical Mental No Disability

All information contained in this application is confidential and is for the intended recipient only. I further understand that, with the exception of purposes related to treatment, access to, uses and disclosures of, and requests for an individual’s health information must, to the extent practicable, be limited to the minimum necessary to accomplish the intended purpose of the approved use, disclosure or request