1:17 Discipleship Program Application
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Sobriety Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
In about a page, tell us a little bit about yourself and your recovery journey
*
Why are you interested in this program?
*
Who is Jesus to you?
*
What does it mean to you to be a disciple?
*
What are your current faith habits?
*
What are your greatest strengths/gifts?
*
What are your biggest hurdles/weaknesses?
*
What do you think healthy recovery looks like?
*
What are your goals over the next year? Five years?
*
This program calls for undivided focus and commitment. Are you willing to abstain from dating and make sacrifices regarding employment if it conflicts with our ability to help you grow into a mature disciple of Christ?
*
Yes
No
Is there anything else you would like us to know or consider?
*
Reference
(non-family preferred)
Reference Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
Signature Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I want to Become a Disciple
I want to Become a Disciple
Should be Empty: