Sisters 4 Hope Foundation

Sisters 4 Hope Foundation

Residential Program Application
Which residential program are you applying to?*
PLEASE NOTE: WE WILL NOT ACCEPT ANYONE WITH A FELONY OR A HISTORY OF VIOLENCY OR ABUSE TO CHILDREN OR ADULTS.
Personal Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
Are you in an active romantic relationship with a man?*

YesNo
If you answered "Yes" to the previous question, please list the information below.
Do you have children?*

If you answered "Yes", please provide the information below:

	Name	Age	Date of Birth	Father's Name
Child 1
Child 2
Child 3
Child 4
Child 5

List your favorite pastimes or hobbies.*
Education & Service Information
What is the highest level of education or grade you have completed?*
Do you enjoy learning?*
List any post-high school education or training you have had.*
What are your future educational goals?*
Military Service

Employment History
What is your current employment status?*
If you selected "Other", please explain.
If you are currently employed, please provide the information below:
Are you physically, emotionally, and mentally able to handle full-time work?*
What is the minimum wage you are willing to work for?*
What types of work do you enjoy?*
Do you have any prospects for future employment where you are ready to work?*
If you answered "Yes" to the previous question, please complete the information below:
Criminal Justice History

PLEASE NOTE: WE WILL NOT ACCEPT ANYONE WITH A FELONY OR A HISTORY OF VIOLENCY OR ABUSE TO CHILDREN OR ADULTS.
Have you ever been convicted of a felony?*
Have you ever had any other criminal charges?*

If you answered "Yes" to the previous question, please complete the information below:

	Jurisdiction	Charge	Date	Outcome
Charge 1
Charge 2
Charge 3
Charge 4
Charge 5

If you have been in prison, please list the facility name, charge, and date below:

	Date	Facility Name
Charge 1
Charge 2
Charge 3
Charge 4
Charge 5

Please list any legal issues currently pending.*
If not applicable, put N/A.
Are you currently on parole or probation?*
If you answered "Yes" to the previous question, please provide the information below:
Have you in the past or currently under Megan's Law or Texas Sex Offender Law?*
PLEASE NOTE: WE WILL NOT ACCEPT ANYONE WITH A FELONY OR A HISTORY OF VIOLENCY OR ABUSE TO CHILDREN OR ADULTS.
If you answered "Yes" to the previous question, please provide the date the order expired.*
If not applicable, put N/A.
Did you have any misconduct charges while in prison?*
If you answered "Yes" to the previous question, please describe each misconduct charge with the date.*
If not applicable, put N/A.
What needs to change in your life, so you do not go back to prison?*
If you answered "Other" to the previous question, please explain.*
If not applicable, put N/A.
Spiritual Background
Where are you currently in your faith journey?*
Have you accepted Jesus Christ as your personal Lord and Savior?*
If you answered "Yes" to the previous question, are you committed to following Jesus?*
Do you have a home church that you regularly attend?*
If you answered "Yes" to the previous question, please explain:
Medical History
Please list any current medical conditions & any history of serious illnesses.*

Please list any medication you are currently taking.*

	Purpose
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10

Please provide your Physician information below.
Do you have medical insurance?*

In case of an emergency, who should be contacted?*

	First Name	Last Name	Phone Number
Emergency Contact 1
Emergency Contact 2

Sobriety
Are you currently clean and sober?*
Have you recently struggled with any of the following addictions?*
If you answered "Other" to the previous question, please explain. If not applicable, put N/A.*

Please list all recovery, rehab programs, or ministries that you have previously participated in along with dates of participation.*

	Started	Completed	Not applicable
Program 1
Program 2
Program 3
Program 4
Program 5

Are you currently involved with an AA/NA/CR Group?*
If you answered "Yes" to the previous question, what is your home group?*
If not applicable, put N/A.
Family History

Please provide the information below:*

	Full Name	Occupation	Phone Number	Unknown
Father's Information
Mother's Information

Describe any changes that should happen in your relationship with your parents.*
Briefly describe any history of addictions in your family.*
Are there any other significant family relationships or issues we should be aware of?*
General Information
Why do you want to participate in the Sisters 4 Hope Residential Program?*
If you answered "Yes" to the previous question, please explain:*
If not applicable, put N/A.
What are the goals you want to accomplish while in the Sisters 4 Hope Residential program?*
Explain how you will commit to and respect the rules and objectives of the Sisters 4 Hope Residential Program. If you feel you cannot commit to the rules and objectives, explain why you cannot and why you should still be accepted.*
I have read and understand the Sisters 4 Hope Residential Program rules and objectives and agree to abide by them as long as I live in any of the Sisters 4 Hope residential locations. 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, and other activities as determined by staff. I am asking for help to turn from my old lifestyle and establish a new identity in Jesus Christ in which I have victory over destructive habits and am empowered to fulfill His call over my life. *
Signature

Clear
We at Sisters 4 Hope Foundation commit to being a supportive and Christ-Centered program that brings life formation. We will strive to create and maintain a safe environment in which each person is respected, held accountable, and inspired to grow.
Should be Empty:

Personal Information

Education & Service Information

Employment History

Criminal Justice History

Spiritual Background

Medical History

Sobriety

Family History

General Information