Potter's House Men's Application

MEN'S STUDENT APPLICATION
•Purpose: The following information will be used to determine the fit between the applicant and The Potter’s House program. In addition, it will provide staff a helpful understanding with which to support new beginnings while at The Potter’s House. All information will be Confidential and for use only by those who oversee the program. All applicants must be willing to agree to complete the program, regardless of time required.
1. Personal Information
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Male/Female*

MaleFemale
Age*
Date of Birth*

MonthDayYear
Date
Marital Status*
Are you in an active relationship? *
Spouse's Name

First NameLast Name
Spouse's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Phone Number

Area CodePhone Number
Spouse's Occupation
Do you have children?
Child Support?
How much do you currently owe on child support?
Child's Name: Type a label Age:
Birth Date:
Child's Name: Age:
Birth Date:
Child's Name: Age:
Birth Date:
Child's Name: Age:
Birth Date:
Child's Name: Age:
Birth Date:
List all previous spouses (if applicable).

2. Education and Service Information
What is the highest grade you have completed?
List any specific areas of training you have had.
What are your future educational goals?
List your four favorite pastimes/hobbies.

3. Employment History
What is or was your most current employment status (place, position)?
How long have you been or were you employed there?
Can you return?
Are you physically, emotionally and mentally able to handle full-time work?

4. Criminal Justice History
Have you ever had any criminal charges?*
List all local, out of the country, and out of state charges and the dates
How many times have you been in prison?
What were the charges and the dates of each stay? (see Criminal Charges Statement signature form—last page)
Do you have any upcoming court cases/legal issues pending?*
Explain:
Probation/Parole:
How long?
Present (or past) Probation/Parole Officer:

First NameLast Name
Phone Number

Area CodePhone Number
Do you come under Megan’s Law as a sex offender? *
Any sexually related charges or convictions?*
Do you have any misconduct charges while in prison?
How many misconducts did you have?
What where the misconducts for?
What needs to change in your life, so you do not go back into prison? (Select all that apply)

People, places and thingsBeing a followerStay away from drugs and alcoholStay away from bad/unhealthy relationshipsBe more responsible in keeping a jobDeal with the reason I go to drugs and alcoholDevelop a meaningful relationship with Christ that impacts my day to day function.Other

5. Spiritual
Have you accepted Jesus Christ as your personal Lord and savior?
Are you committed to following Him?
Most recent church attended:
Do you have a home church? Name:
Present Chaplain/Pastor’s Name:

First NameLast Name
Phone Number

Area CodePhone Number

6. Medical/Mental Health History
List any current medical conditions and any history of serious illness.
Have you ever been diagnosed with Hepatitis?
If Yes, check one:

ABC
Have you received medical care for this?
Has it been cured/resolved?
When?

MonthDayYear
Date
Have you ever been diagnosed with any mental health conditions?
If Yes, what was the diagnosis?
Date you were diagnosed?

MonthDayYear
Date
What mental health medications have you been prescribed in the past? Name, Dose & Purpose
What medications are you taking currently? (and intend to bring/take at Potter’s House) Name, Dose & Purpose
***NOTE: YOU MUST ENTER WITH 30 DAYS OF MEDICATION---no exceptions***
Do you have medical insurance?
In case of emergency, who should be contacted?

First NameLast Name
Phone Number

Area CodePhone Number

8. Family History
Father’s Name

First NameLast Name
Phone Number

Area CodePhone Number
Mother's Name

First NameLast Name
Phone Number

Area CodePhone Number
Describe any changes that should happen in your relationship with your parents
Describe briefly any history of addictions in your family.
Are there any other significant family relationships or issues we should be aware of?

9. General Information
Why do you want to live at The Potter’s House? (Mark all that apply)

I need a place to liveI can’t go back home anymoreI need accountability with learning how to live in my community.I need a home plan.I need more structure in my lifeI desire to grow in faith and discipleshipOther
What are the goals you want to accomplish while at The Potter’s House?
Explain how you will commit to and respect the Objectives of The Potter’s House PartnershipPlan? If you feel you cannot commit to the plan, explain why you cannot and why youfeel you should still be accepted.
Write a 1-2 page summary of the key events that have shaped you to this point in your life.
Include a brief testimony to the impact that Jesus has had and your short-term and long-term future goals.

How do you see Potter’s House helping you to achieve them?

CRIMINAL CHARGES STATEMENT
I blanks , am acknowledging through this statement, and as listed on The Potter’s House application, that I have no criminal charges that are related to the following offenses:

• Egregious Acts of Violence
• Arson
• Rape or any Sexually Related charges in general.

I am also attesting to the fact that I am not listed on Megan’s List.

---------[INMATE must have this section below completed by official]: -------------
This statement has been witnessed and confirmed by the following legal/correctional/probationary official: Legal / Prison Official Name

First NameLast Name
Official Title/Position

Please review the program information and, if interested in admission, complete the following application, sign this form, and submit the application and form to the Potter’s House for review.

I, First Name Last Name , have read The Potter’s House Phase One Guidelines and agree to abide by them as long as I am in “the hands of the Potter.” I understand that this is both a discipleship and a recovery-oriented program. By signing this agreement, I commit myself to adhere to the rules, financial responsibilities, counseling, and other activities as determined by staff. I am asking for help to turn from my old lifestyle, and becoming a “new creation” in Jesus Christ as I transition back into the community.
Signature & Date

Clear
We the Potter’s House staff commit to doing our part in providing a helpful, Christ-centered,
life changing program. We will strive to create and maintain a healthy environment in which each person is respected and inspired to personal growth.

While you wait for approval:
1. Pray for Gods guidance to be sure that the Potter’s House is His will for your immediate future.
2. Ask your family, church, and other individuals for guidance in this area.
Please verify that you are human*

PROGRAM FEES OVERVIEW
Phase One (3 months): $1800 per month

Phase Two (6 months): Based on employment income

NOTE: The Potter’s House does not deny admission based on lack of program fees.

• Within the first 30 days of entrance to Phase One, you will meet with our Finance team to evaluate your personal financial status, needs, and goals—as how this relates to paying toward your program fees.

• Upon entrance to Phase Two you will be assisted in obtaining full-time employment with a local employer. (Average income is usually between $15-$18/per hour)

• After 2 weeks in Phase Two, you and our Finance team will establish a working budget that is crafted specifically to your individual needs. This will assist you in submitting a portion of your income to your program fees—and toward any debt, child support, fines, etc. you may have incurred prior to entrance –as well as developing a saving account.

• Keep in mind the more you are able to pay towards your program fees upon entrance will help to lessen the payment amount toward your program fees.

• Do not let finances/fees deter your decision to enter. All plans created with the Finance team are fair, easily manageable, and designed for your financial stability beyond The Potter’s House.
Should be Empty:

MEN'S STUDENT APPLICATION

1. Personal Information

2. Education and Service Information

3. Employment History

4. Criminal Justice History

5. Spiritual

6. Medical/Mental Health History

7. Sobriety

8. Family History

9. General Information

CRIMINAL CHARGES STATEMENT

PROGRAM FEES OVERVIEW