Mt Zion House Application

Applicant Information

Name:

Date:

Current address:

City:

State:

ZIP Code:

Phone:

Date of Birth:

Place of Birth  City:

State:

Height/Weight:

Race:

Hair Color:

Tattoos:  Yes____  No____  If yes, describe:

Social Security Number (Must have a social security card and valid picture ID)

How long?

Drivers License Number:

Expiration Date:

State:

Do you have any physical disabilities or defects?  Yes____  No____

If yes, explain:

How would you rate your health?  Poor____  Fair____  Good____

Are you taking any prescription drugs or medication?  Yes____  No____  If yes, please list

For what purpose?

What drugs are you taking that are non-prescription?

Have you ever been tested for AIDS?  Yes____  No____    Are you HIV positive?  Yes____  No____

Have you ever been tested for Hepatitis A, B, or C?  Yes____  No____    Are you Hepatitis A, B, or C positive?  Yes____  No____

Have you ever tested positive for Syphilis?  Yes____  No____  Gonorrhea?  Yes____  No____  Chlamydia?  Yes____  No____

Are you currently under the care of a physician?  Yes____  No____    A Psychiatrist?  Yes____  No____

If yes, have you ever been diagnosed with a mental illness?  Yes____  No____    If yes, what illness?

Military service?  Yes____  No____    If yes, what branch?                                 How long?

Last grade completed in school                                           List job skills

Have you ever been arrested?  Yes____  No____    How many times?   

Please list dates and reasons  (be specific)

Have you ever spent time in prison?  Yes____  No____  How long?                     Where?

Are you on probation or parole?  Yes____  No____ 

If yes, agents name:                                                   County:                         Telephone number:

Do you have any warrants for your arrest?  Yes____  No____

Have you ever assaulted anyone?  Yes____  No____    If yes, were you under the influence of drugs or alcohol?  Yes____  No___

Have you ever committed the act of murder?  Yes____  No____   

Have you ever molested a child?  Yes____  No____  If yes, male or female  (circle one)

How old was the child?                                How old were you?                         How many times?

Have you ever raped anyone?  Yes____  No____

Have you ever thought about suicide?  Yes____  No____        Have you ever attempted suicide?  Yes____  No____

If yes, by what means did you try and how many times?

Are you a homosexual?  Yes____  No____        Are you a bisexual?  Yes____  No____

Is anger a problem with you?  Yes____  No____        Have you ever been divorced?  Yes____  No____ 

Are you in debt?  Yes____  No____  If yes, how much?

Are you a drug addict?  Yes____  No____    What is your drug of choice?

Are you an alcoholic?  Yes____  No____      Do you smoke?  Yes____  No____

Do you consider yourself addicted or attracted to pornography?  Yes____  No____

What is your religion?                                Do you attend church?  Yes____  No____   

Do you pray?  Yes____  No____  If yes, how often?

Do you believe in God?  Yes____  No____  Do you read the Bible?  Yes____  No____  If yes, how often?

Who do you say Jesus is?

Are you born again?  Yes____  No____  How long have you been a Christian?

Have you been baptized in water?  Yes____  No____  When?

Have you been baptized in the Holy Spirit?  Yes____  No____  Uncertain____

Explain why you want to be admitted to Mt Zion House:

Contact INFORMATION

Contact Person:

Phone:

Father’s name:

Address:

Phone:

Mother’s name:

Address:

Phone:

Wife’s name:

Address:

Phone:

Children’s names:

Who has custody of the children?

Siblings names:

Name:                                   M    F        Age:

Name:                                   M    F        Age:

Name:                                   M    F        Age:

Name:                                   M    F        Age:

ACKNOWLEDGEMENTS

Do you understand and accept that we use only the Word of God for all teaching, counseling, and instructing?  Yes____  No____

Do you understand and accept that this program is Christian based?  Yes____  No____

Is all the information that you gave true to the best of your knowledge?  Yes____  No____

The Bible says that you shall know the truth, and the truth shall set you free and you will be free indeed.  Are you ready to be set free?  Yes____  No____

SIGNATURES

I agree that by signing this application I am making a minimum 26-week commitment to Mt Zion House.  I understand that I must be faithful in all that is required of me in order to graduate the program.  I agree to abide by all the rules of Mt Zion House.

Signature of applicant:

Date:

Signature of director:

Date: