second chance form

First Name

Last Name

Phone Number

Date of Birth

Were you released from Prison within the last 12 months? If so, from which facility?

Did you attend any Islamic services while there? If so, which ones?

Did you obtain any education or higher education? If so, what?

Did you participate in any Institutional programs offered for Mental health? If so, which ones

Are you currently using drugs or alcohol? If so, for how long?

Where are you currently staying and sleeping during the night?

Are you currently employed? If so, for how long?

Who referred you to Islam in Prison?

Please provide any additional information that you wish for us to know that may help us know more about you and your current situation so that we may know how to best serve you with our programs.

second chance form

islam in prison

Get In Touch

Furqaan Divisions

Furqaan projects