Revitalize Application

Participant Application

Fill out the application carefully
Participant Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant E-mail*
example@example.com
Mobile Number*
Are you currently employed?*

YesNo
Highest Level of Education*
Marital Status*

SingleMarriedDivorcedWidowedSeparated
Do you have children?*

YesNo
If yes, do your children live with you?*

YesNo
Have you ever been incarcerated?*

YesNo
If yes, list the dates and charges of your incarceration.*
Do have any pending legal issues or court dates?*

YesNo
If yes, list the details of the legal and court issues.*
Are you on probation or parole?*

ProbationParoleNone
If you are on probation or parole, please give specific details, the county, and state.*
Have you ever been in a recovery program?*

YesNo
Do you have a history of drug and/or alcohol addiction?*

YesNo
Do you currently struggle with drug and/or alcohol addiction?*

YesNo
What is your drug(s) of choice?*

AlcoholMethamphetamineHeroineBenzodiazepineNoneOther
When is the last time you used drugs or alcohol? What did you use?*
Have you been through detox?*

YesNoN/A
Are you struggling with issues unrelated to addiction? (Ex. Depression, anxiety, general unmanageability, desire for spiritual, emotional, and mental revitalization)*
Write a paragraph on why you want to participate in Revitalize.*
List 5 goals you want to accomplish through this program.*
What are your dreams for your future?*
Is there anything else you feel like we need to know?*
Your belief or lack of belief in God is not a requirement for this course. However, because of what we believe to be true about God and the nature of what we teach through the lens of the Gospel, we would like to know a little about you in this area.
What do you believe about God?*
Who do you say Jesus is?*
How did you hear about Revitalize?*
By submitting this application, I am certifying that all of the information I have given is true to the best of my knowledge. I also acknowledge that by being a participant of Revitalize, I will be subject to a drug and alcohol test at intake and randoms throughout the 6-weeks. I understand there is a fee of $400 before the course begins or $75 weekly, if accepted.
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Participant Application

Your belief or lack of belief in God is not a requirement for this course. However, because of what we believe to be true about God and the nature of what we teach through the lens of the Gospel, we would like to know a little about you in this area.