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Well of Hope

PERSONAL INFORMATION

First name*

Last name*

Birthday*

Month

Day

Year

Phone*

Address*

Emergency Contact Name:*

Relationship*

Phone Number*

SPIRITUAL BACKGROUND

Are you currently attending church?*

Yes

If yes, which one?*

How would you describe your current relationship with God?*

Why do you want to be part of this ministry home?*

What areas of your spiritual life are you seeking to grow in?*

Prayer

Bible Study

Fellowship

Healing/Recovery

Other

What do you personally feel like you need recovery from (i.e. drugs, alcohol, etc)?*

LIVING HISTORY

Do you have any history of:*

Substance Abuse

Incarceration

Domestic Abuse

Homelessness

Mental Health Struggles

None of the above

If you have a histroy of any of the above, in a few words, please elaborate:*

Do you have any criminal history?*

Yes

If so, please give a brief explanation of your criminal history*

Are you willing to submit to a background check?*

Yes

*NOTE: A criminal history may not exclude you from participating in this ministry.

Are you currently working or attending school?*

Yes

If yes, where?

Marital status:*

Single

Married

Divorced

Do you have any dependants or legal obligations that may affect your residency?*

Yes

If yes, please explain:*

Do you have any children?*

Yes

If yes, who do your children reside with:

MEDICAL HISTORY

List any current medical conditions that may affect your particiaption in this program:*

List any prescription medications that you are currently taking, including any routine over the counter medications:*

COMMITMENT & AGREEMENT

Well of Hope is a Christ-centered living environment. Residents are expected to participate in daily/weekly spritual activities, respect house rules, and commit to peronal and spritual growth.

Are you willing to participate in Bible studies, church services, and community chores?*

Yes

Are you willing to follow house rules and be accountable to ministry leadership? *

Yes

Signature*

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Date*

Month

Day

Year

A Ministry of Huffman First Pentecostal Church of God

"Let us therefore come boldly unto the throne of grace, that we may obtain mercy, and find grace to help in time of need." - Hebrews 4:16

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