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Renewed Life Ministries Outreach
1
General Information Application
2
Emergency Information
3
Financial Information
4
Educational Information
5
Legal Information
6
Statement of Agreement
General Information Application
Name
*
Date of Birth
*
Prior Faith-Based Programs
*
Drivers License: State
*
Number
*
Marital Status
Single
Married
Separated
Divorced
Widowed
Children
No
Yes
If So, How Many
*
Ages
*
Separate with commas.
Emergency Information
Name
*
Relation
*
Address
*
Phone
*
Name
*
Relation
*
Address
*
Phone
*
Are you taking any prescribed medication?
*
No
Yes
Explain
Do you have any physical disabilities that would keep you from working in a factory?
Financial Information
Are you receiving: welfare, unemployment, disability, workman’s comp, alimony or other income?
*
No
Yes
If Yes, explain
Do you have any debts?
*
No
Yes
If Yes, explain
Educational Information
Last Grade Completed
*
Year
*
Please enter a value between
1950
and
2018
.
Have you received a G.E.D.?
*
No
Yes
If yes, what Year
Please enter a value between
1950
and
2018
.
Legal Information
Are you on probation?
*
No
Yes
If yes, for how long
Have you served any time in a state or federal prison?
*
No
Yes
If yes, when and where?
Probation/Parole Officer
Phone
P.O.’s Address
Terms and Conditions of your probation/parole
Do you have restitution to pay?
No
Yes
If yes, how much
Do you have a valid Drivers License?
*
No
Yes
Explain
Do you have a Social Security Card?
No
Yes
Explain
Statement of Agreement
I have read the Guidelines of Renewed Life Ministries, and with full understanding, I agree to cooperate or be subject to discipline or dismissal. Student Signature_________________________________________________________ Staff Signature___________________________________________________________ I understand that Renewed Life Ministries cannot be held responsible for personal injury, for illness (due to personal neglect or abuse of a medical condition), for payment of medical care or personal property of anyone in the program. Any personal property or money left over seven (7) days becomes the property of Renewed Life Ministries. If I leave the program I am responsible for my personal belongings. Renewed Life Ministries will not send my personal belongings to me. I understand if I do not cooperate with the rules and regulations, I will be asked to leave. Student Signature_______________________________________Date______________ Staff Signature___________________________________________________________
Signature
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