Open Door Christian Center Application

Hope Recovery is a ministry of The Open Door Christian Center, Clinton, SC.

Please fill in the form below. All questions with * must be answered in order to submit.
PERSONAL INFORMATION
Full Name*

PrefixFirst NameLast Name
Biological Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Emergency Contact*
Name and Number
E-mail
Additional Contact
Birthdate*

MonthDayYear
Age
Are you homeless?

YesNo
Can you read?

YesNo
Social Security Number*
Valid ID/Drivers License/State
Marital Status: Are you legally married?*
Children?

YesNo
If children list names and ages.
US Citizen:*
Military Service:
Education Level:
LEGAL MATTERS
Have you ever had a CDV?*
Have you ever had a sex offender charge?*
Have you ever been convicted of a felony?*
If yes, what and when:
List all pending court dates, jail terms, charges, etc:
Are you court ordered to enroll in a facility?*
Are you under bond?*
If yes, county and state
Do you have a probation agent?*
If yes, add agents Name and Phone.
HEALTH STATUS
Are you required to have a special diet?*
If yes, explain:
List any Medical Issues, If None then type - "None"*
Are you under a doctor's care:*
If yes, why:
Are there any health, (Mental or physical) issues you have that would keep you from working?*
If yes, please explain:
List all medical conditions (bi-polar, handicapped, schizophrenia, Depression etc.)
List any medications you are currently taking: If None type "None"*
List Drug of choice:*
When was the last time you used and how much?*
Have you ever had convulsions, seizures, or blackouts?*
List any allergies, food or otherwise if none type none*
ADDITIONAL QUESTIONS
Have you ever received food stamps (SNAP/EBT)?*
If yes, is it current?
Do you have it on you?*
If No can you get it?
Do you have a picture ID?*
Do you have a Social Security Card?*
Do you have any source of income?
If yes, what type?
By checking yes, I give authorization to Open Door to conduct a background check, consult with your Probation Officer and/or your attorney regarding your legal situations:*

Yes, I give Open Door permissionNo, I do not give Open Door permission
GENERAL INFORMATION
Hope Recovery is a Christian program, a ministry of the Open Door Christian Center, Inc., Clinton, SC.. We are not a healthcare facility. This is a 90 day in house program. However, you may be here over 90 days since we only graduate once per month. You will not get a certificate of completion unless you stay until graduation night. Hope Recovery is a multi-dimensional approach involving a strong Christian approach with recovery meetings; Christian based 12 steps, along with church services and bible studies. We ask you to call in daily to check on your status. And if you choose to go elsewhere, please let us know.
How did you hear about the open door Christian Center recovery program?
Are you willing to do whatever it takes and to commit to this 90 day program if accepted?*
Do you have any questions?
Will you call the office the next day, Monday thru Saturday, to check on the status of your app. between the hours of 8 AM and 12 Noon?
Application Date:*

MonthDayYear
Date
Should be Empty:

Hope Recovery is a ministry of The Open Door Christian Center, Clinton, SC.

PERSONAL INFORMATION

LEGAL MATTERS

HEALTH STATUS

ADDITIONAL QUESTIONS

GENERAL INFORMATION