NEW North County Tattoo Removal Application

North County Tattoo Removal Program

Tattoo Removal Application

PLEASE READ BEFORE COMPLETING THE APPLICATION !
In order to qualify for the North County Tattoo Removal Program you must meet the following criteria:

1. Live in North San Diego County(Poway, Rancho Bernardo, Escondido, Fallbrook, San Marcos, Vista, Carlsbad, Oceanside).
2. Have visible gang related tattoo(s) such as on head, face, neck, hands, etc. Non-visible tattoos (such as back, chest, feet, etc.) will NOT be accepted.
3. No longer have contact with gangs, gang members or gang activity.

*Note: There is no age requirement for the program; but, priority will be given to those between the ages of 18-35.

**Please allow up to three weeks to hear a response regarding your application. **

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. Date of Birth:

Date / Time

Date

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* 4. What is your sex?

Female

Male

Intersex

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* 5. Age:

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* 6. Are you a resident of North San Diego County? "North" refers to the cities of Poway, Rancho Bernardo, Escondido, Fallbrook, San Marcos, Vista, Carlsbad, Oceanside.

Yes

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* 7. What is your address?

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* 8. Please provide a phone number where we can best reach you.

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* 9. What is your email address?

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* 10. Have you ever been arrested?

Yes

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* 11. If yes, list the charge(s). (Enter "N/A" if you have not been arrested)

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* 12. If you were incarcerated, what was the date of your release?

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* 13. If yes, what is the date of your last arrest?

Date / Time

Date

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* 14. If yes, what is your Probation/Parole Officer's name and phone number?

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* 15. Are you currently on Probation or Parole?

Yes

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* 16. How many visible tattoos do you have?

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* 17. Where are your visible tattoos located? (Mark All That Apply)

Head

Face

Hand(s)

Neck

Forearm(s)

Other (please specify)

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* 18. My tattoos are...(Select All That Apply)

Black Ink

Color Ink

Were applied at a tattoo shop

Were applied while incarcerated

Were applied by someone other than at tattoo shop

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* 19. I got my tattoo(s) to represent a gang or gang life.

True

False

Not Sure

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* 20. My tattoo(s) can be described as...(Pick the one that most closely applies)

Small (size of a quarter)

Medium (size of a dollar bill)

Large (covers most of the area)

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* 21. My tattoo(s) have kept me from...(select all that apply)

Getting employment

Leaving a gang

Getting a fresh start

Feeling positive about my future

Other (please specify)

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* 22. Have you earned a high school diploma or high school equivalency(GED or HiSET)?

Yes

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* 23. Are you attending school? (Select whichever applies)

High School

Adult Education

Trade/Vocational School

Community College

University

Not attending school at this time

Other (please specify)

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* 24. Are you currently employed?

Yes

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* 25. How did you hear about this program?

Probation/Parole

Community Agency

School

Law enforcement

Faith Community

Medical doctor/clinic

Family/Friend

Media

Other (please specify)

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. Date of Birth:

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* 4. What is your sex?

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* 5. Age:

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* 6. Are you a resident of North San Diego County? "North" refers to the cities of Poway, Rancho Bernardo, Escondido, Fallbrook, San Marcos, Vista, Carlsbad, Oceanside.

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* 7. What is your address?

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* 8. Please provide a phone number where we can best reach you.

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* 9. What is your email address?

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* 10. Have you ever been arrested?

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* 11. If yes, list the charge(s). (Enter "N/A" if you have not been arrested)

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* 12. If you were incarcerated, what was the date of your release?

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* 13. If yes, what is the date of your last arrest?

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* 14. If yes, what is your Probation/Parole Officer's name and phone number?

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* 15. Are you currently on Probation or Parole?

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* 16. How many visible tattoos do you have?

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* 17. Where are your visible tattoos located? (Mark All That Apply)

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* 18. My tattoos are...(Select All That Apply)

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* 19. I got my tattoo(s) to represent a gang or gang life.

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* 20. My tattoo(s) can be described as...(Pick the one that most closely applies)

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* 21. My tattoo(s) have kept me from...(select all that apply)

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* 22. Have you earned a high school diploma or high school equivalency(GED or HiSET)?

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* 23. Are you attending school? (Select whichever applies)

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* 24. Are you currently employed?

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* 25. How did you hear about this program?

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* 26. Why is it important for you to have your tattoo(s) removed?