Resident Application

The Way Ministry Application for Residency
Name

First NameLast Name
Any Other Names Married Maiden Nickname
YESNO
Social Security Number
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
County
Driver's License Number
State
ValidExpiredSuspendedNew Applied
If you do not have your license, what will it take for you to get one?
YesNo
YesNo
Birth date

MonthDayYear
Date
Age
YesNo
Who with
Probation/parole officer name and contact info county and state info
Pending Court dates/charges
Do you have any violent or sexual misconduct charges
What is your drug of choice
What will you test positive for
Current prescribed medications (if none please state none)
Do you have any dental problems or foresee any dental problems in the next 6 months
Do you have any medical conditions or mental diagnosis
YesNo
Do you have any allergies
SingleDivorcedWidowedIn a relationship over 1 yearIn a relationship less than 1 year
Do you have any children? How many? Their Names?
Do you have an open DCFS case (contact caseworker information)
If you do not have a DCFS case and have children, where and whom are they with?
Do you have a relationship with the caretakers of your children
Are you pregnant
Why are you seeking a faithbased program of recovery
Have you ever been in a program If so where when and did you complete and if not why will this time different
Emergency Contact Information and Relationship
Who or how were you referred to our program
I agree to allow The Way Ministry to discuss my background and treatment with other professional agencies. I understand that the staff may need to check on my legal standing and criminal background.
I understand that I am consenting to random searches and drug/alcohol testing as part of this agreement.

I understand that I am granting permission for the staff of The Way Ministry to contact the appropriate authorities in the event of a medical emergency or criminal activity. I understand that I am giving The Way Ministry staff permission to contact any/all names and facilities on this application. I also agree to release The Way Ministry from any claim of damages or losses incurred while living at the Ministry.
Printed Name
Date

MonthDayYear
Date
Signature
Witness
Date

MonthDayYear
Date
Jamie Mann 870-819-2396

Office Number 870-253-3322

Mailing Address: The Way Ministry 1711 Paragould Plaza PMB 114
Paragould AR 72450

website: the-way-ministry.weebly.com

Email: thewayministry2020@gmail.com

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