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? (Required.)

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2. What is your last name?
(Required.)

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3. Date of Birth:
(Required.)

Date / Time

Date

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4. What is your sex? (Required.)

Female

Male

Intersex

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5. Age:
(Required.)

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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. (Required.)

Yes

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7. What is your address? (Required.)

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8. Please provide a phone number where we can best reach you. (Required.)

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9. What is your email address?
(Required.)

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10. Have you ever been arrested? (Required.)

Yes

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

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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? (Required.)

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15. Are you currently on Probation or Parole? (Required.)

Yes

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16. How many visible tattoos do you have? (Required.)

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

Head

Face

Hand(s)

Neck

Forearm(s)

Other (please specify)

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

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. (Required.)

True

False

Not Sure

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

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)
(Required.)

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)? (Required.)

Yes

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

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?
(Required.)

Yes

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25. How did you hear about this program?
(Required.)

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? (Required.)

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* 2. What is your last name? (Required.)

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* 3. Date of Birth: (Required.)

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* 4. What is your sex? (Required.)

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* 5. Age: (Required.)

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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. (Required.)

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* 7. What is your address? (Required.)

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

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* 9. What is your email address? (Required.)

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* 10. Have you ever been arrested? (Required.)

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

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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? (Required.)

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* 15. Are you currently on Probation or Parole? (Required.)

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* 16. How many visible tattoos do you have? (Required.)

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

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

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

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

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

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

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

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* 24. Are you currently employed? (Required.)

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* 25. How did you hear about this program? (Required.)

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

1. What is your first name? (Required.)

2. What is your last name?
(Required.)

3. Date of Birth:
(Required.)

4. What is your sex? (Required.)

5. Age:
(Required.)

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. (Required.)

7. What is your address? (Required.)

8. Please provide a phone number where we can best reach you. (Required.)

9. What is your email address?
(Required.)

10. Have you ever been arrested? (Required.)

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

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

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

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

15. Are you currently on Probation or Parole? (Required.)

16. How many visible tattoos do you have? (Required.)

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

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

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

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

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

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

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

24. Are you currently employed?
(Required.)

25. How did you hear about this program?
(Required.)

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