Men's Renew Application
Please fill out completely and honestly
Full Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Please upload a photo of your state- issued ID:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a current photo of yourself:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Family Information
What is your marital status?
*
How many children do you have? What are their names/birthdates?
*
Do you owe alimony or child support? If so, how much? Do you have a payment plan?
*
Education History
Did you graduate high school? If so, where and when?
*
Did you attend college? If so, where and when? What was your major? Did you earn a degree?
*
Did you attend trade school? If so what is your trade? Tell us your experience.
*
Work History
What is your usual occupation?
*
Are you currently working? If so, where? If not, why?
*
Please list the last 5 places you worked and how long you worked there. Why did you leave those jobs? Be specific.
*
Medical
Do you have medical insurance?
*
Yes
No
Insurance agency and policy number.
*
What is the state of your health? Are you able-bodied? Please be specific
*
Have you ever been treated and or diagnosed for psychiatric illness?
*
Yes
No
Have you ever been diagnosed as Bipolar or Schizophrenic? If so, please explain.
*
Have you ever suffered from depression?
*
Yes
No
List all major injuries, illnesses and/or surgeries that you have had:
*
When were you last tested for HIV?
*
When were you last tested for Hepatitis C?
*
Do you smoke, vape or use any type of tobacco/nicotine?
*
Yes
No
Are you currently taking taking any prescription(s) and/or over the counter medicine? If so, what are you taking and what is the dosage?
*
Life History
Are you a veteran?
*
Yes
No
How long were you in the service? Date and type of discharge. If discharge was not honorable, please explain
*
Have you ever considered committing suicide? When?
*
Have you ever attempted suicide? When and why?
*
Do you struggle with alcohol or drugs? If yes, please be specific.
*
What is your drug(s) of choice? At what age was your first drinking or drugging experience?
*
What is your longest period of sobriety?
*
When did you last drink or get high? What did you drink/use?
*
Please list any rehabilitation centers you have attended, when you attended and how long it was?
*
What is your sexual orientation?
*
Legal
Have you ever been arrested? How many times?
*
Please list from newest to oldest, all charges, date of arrest, and time served for each.
*
Have you ever been charged or convicted with a sexual crime? If so, please explain.
*
Do you currently have any legal matters pending? If so, please explain.
*
Do you have any open warrants for your arrest?
*
Yes
No
Are you currently on probation or parole?
*
Yes
No
Spiritual Background
What is your church affiliation? How often/long have you attended?
*
Have you accepted Jesus Christ as your Lord and Savior?
*
Yes
No
Please briefly share your testimony.
*
How often do you read the bible and pray?
*
Renew
How did you hear about Renew?
*
Do you understand that Renew requires a minimum of a one year commitment?
*
Please share your motivation for seeking help.. Please be honest and specific.
*
Will you need to detox before coming into the ministry?
*
Are there any dates/events coming up that you would be requesting to leave the property during your commitment? (i.e. probation, court dates, etc.)
*
If you were accepted into Renew today, is there anything not listed above that we would need to know? If so, please explain below. Failure to disclose important information could result in acceptance into Renew to be denied or dismissal if you have already been accepted.
*
Who is your emergency contact? Name, Phone number, email.
*
Parents or close relatives. Name, Phone number, email.
*
Personal Reference #1. Name, Phone number, email.
*
Personal Reference #2. Name, Phone number, email.
*
Personal Reference #3. Name, Phone number, email.
*
Save
Submit
Should be Empty: