Jacob's Well Ministries Application
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  • Emergency Contact People & #’s (​need 3 contacts​):

  • List all Medicines you are on currently OR have been prescribed by a doctor OR have taken in the past that would affect you currently:

  • Have you ever been diagnosed with a mental condition*
  • Is there now or has there been any person(s) following, stalking, pursuing, etc. you in any way?*
  • Do you have any conditions or handicaps that would make you unable to perform rigorous work duties?*
  • Have you ever been accused or charges as a sexual offender?*
  • Have you ever initiated a phyical altercation?*
  • Are you Pregnant*
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  • Do you smoke?*
  • Have you been to a Jacob's Well Ministries facility in the past?

  • MDOC

  • MDOC?
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  • *Resident will have to have a copy of court order in order to be admitted to JWM.*

  • Drug Court

  • DRUG COURT?
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  • DHS

  • DHS?
  • Service Agreement
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  • Have you complied with all the terms of your service agreement?

  • Other Agency

  • Are you going through another agency?

  • Please list ​ALL​ Legal Business, Court dates AND/OR Dr. Appointments you have in the next six months:

  • Will you need a Letter of Residency emailed or faxed?

  • *A letter of residency will result in only in-house furloughs*

     

  • Does applicant have a Valid Driver’s License they will be able to bring?*
  • If no Driver’s License, does applicant have any other form of ID to bring?
  • Choose one:*
  • Who will be responsible for paying your tuition? If not self, list contact information below*
  • How will you be paying?*

  • Should be Empty: