Abba House Middle Georgia Program Application
Due to the nature of our ministry, it is our policy to not admit clients who have been convicted of violent crimes, sexual crimes or crimes against children or the elderly.
Your Personal Information Section
Today's Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
First Name
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Middle Name or Initial
Last Name
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Your Date of Birth
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Email
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example@example.com
Highest Educational Level Completed
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High School
Vocational/Technical School
Business School
College/University
Enter your Graduation Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Information
Primary Emergency Contact
Primary Emergency Contact
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First Name
Last Name
Relationship to Primary Emergency Contact
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Primary Emergency Contact's Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Emergency Contact's Phone Number
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Area Code
Phone Number
Primary Emergency Contact's Email Address
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example@example.com
Secondary Emergency Contact
Secondary Emergency Contact
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First Name
Last Name
Relationship to Secondary Emergency Contact
*
Secondary Emergency Contact's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Emergency Contact's Phone Number
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Area Code
Phone Number
Secondary Emergency Contact's Email Address
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example@example.com
Your Medical Information
List all medications you are taking
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List any doctors whose care you are under
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List any allergies
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List any medical problems
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Consent and Agreement
Insurance is not provided for accident, injury, or illness on the premises or during transportation to and from Abba House, Inc. for any reason. I understand that I am solely responsible for any medical bills I or any member of my family incur or damage I or any member of my family cause while at Abba House, Inc.. I hereby assume any risks that may be incident to my stay at Abba House, Inc. and agree that neither I nor any of my heirs or assigns will hold Abba House,Inc. Responsible for any damages that occur during my stay at Abba House and I hereby release and relinquish forever any and all claims of any nature whatsoever that might arise out of my stay at Abba House, Inc. , 2089 HWY 41 South, Perry GA 31069. I also understand Abba House, Inc. is a church and that ministry I receive is based on the staff’s understanding of Christian principles and the Holy Bible.
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Yes, I agree to this binding statement.
Signature - By typing my name and submitting this form I agree to abide by the Abba House rules.
Please enter the message as it's shown and then click the Submit button below to finalize your application submission.
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