REVEAL Application
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
E-mail
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Are you a resident of the Center of Hope?
*
Please Select
Yes
No
If yes, what date did you arrive at Center of Hope?
*
-
Month
-
Day
Year
Date
Emergency Contact
First Name
Last Name
Emergency Contact #
Please enter a valid phone number.
Format: (000) 000-0000.
Marital Status
*
Married
Divorced
Widower/Widow
Single
Number of Children?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
Highest Grade Completed:
*
Please Select
High School Diploma
GED
8th
9th
10th
11th
1 Year of College
2 Years of College
Associates Degree
Bachelor’s Degree
Advanced Degree
Do you have the following?
Driver's License?
*
Please Select
Yes
No
Social Security Card?
*
Please Select
Yes
No
Birth Certificate?
*
Please Select
Yes
No
If any of the above are missing, what is required to obtain the missing items?
Do you have any outstanding fines?
*
Please Select
Yes
No
Do you have any outstanding warrants?
*
Please Select
Yes
No
If fines or warrants, what for?
Are you presently working?
*
Please Select
Yes
No
If working, where and what are your hours?
Current Medications
Please list all medications that are being taken
Are taking medications prescribed by doctor?
*
Please Select
Yes
No
Medication & dosage
Medication & dosage
Medication & dosage
All others medications
Have you ever been in a drug treatment program?
Yes
No
If yes, what program and when?
Policies & Guidelines
I agree to the following:
No drug or alcohol use
I agree to submit to random drug testing
I will attend all morning classes (9:00 am, Mon - Thur)
I will attend all evening classes (7:00 pm, Mon - Fri)
I will attend all Sunday worship & special meetings
I will serve on the Crew to assist with Sunday morning set up at 8:45 a.m.
I will serve on the Crew to assist with serving Sunday lunch and clean up.
Working Friday & Saturday is permitted (all work hours must be approved by 614 Corps Officer)
I understand that not adhering to these policies could result in dismissal from the program
Briefly share your salvation experience:
*
What do you hope to gain from the REVEAL ministry?
*
Any other information you would like for us to know?
Submit
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