The Oaks Ministry Housing Program Application

Date of Application

Date

Name*

First NameLast Name

Date of Birth*

Date

Are you currently homeless?*

YesNo

If so, what rendered you homeless?

Current address or location where you are living:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Last known permanent address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current phone number where you can be reached:*

Please enter a valid phone number.

Name of person this phone belongs to:*

Do you have health insurance:*

YesNo

If yes, please list company name and Policy Number:

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number:*

Please enter a valid phone number.

Marital Status:*

MarriedSingleDivorcedOther

Do you have children?*

YesNo

If yes, number of dependent children:

Are you currently pregnant?*

YesNo

Are you currently employed? (We reserve the right to contact employer)*

YesNo

If yes, where?

Number of hours worked per week?

Net pay per week?

Current employer's phone number?

Please enter a valid phone number.

If not currently employed, when and what was your last paying job?*

Are you willing to work full time?

YesNo

Are you current on all financial obligations, i.e. child support, credit card, tax liabilities, etc.?*

YesNo

Are you under any court-ordered financial payment plans or obligations?*

YesNo

Do you have a history of addiction to any substance, alcohol, sex, gambling, etc.?*

YesNo

If yes, name your past addiction(s):

How long have you been addicted?

Length of sobriety from:

	Year(s)	Month (s)	Week(s)	Day(s)
Alcohol
Drugs
Other

Names, dates, and length of stay at previous recovery programs:*

Are you under medical care at this time, including, but not limited to, mental health conditions?*

YesNo

If yes, list the condition(s) you are being treated for and the name and contact information of the doctor(s) providing treatment:*

If yes, what medicines, if any, are you currently on? List medicine, dosage, prescribing doctor and doctor's contact information:*

Do you have a current driver's license?*

YesNo

Do you have a vehicle?*

YesNo

Do you have auto insurance?*

YesNo

Are you attending school?*

YesNo

If yes, how many hours per week?

Do you have a checking account?*

YesNo

Have you ever been convicted of a crime?*

YesNo

Have you ever been convicted of a sexual offence?*

YesNo

Have you ever been incarcerated?*

YesNo

If incarcerated, what was the charge?

Are you on parole or probation? (We reserve the right to contact your Parole Officer)*

YesNo

Probation/Parole Officer's name

First NameLast Name

Probation/Parole Officer's Contact Info.

Please enter a valid phone number.

Do you have any pending legal issues?*

YesNo

List all current/pending charges below

Do you have a personal relationship with Jesus Christ?*

YesNo

The Oaks Ministry Program is a Christ-centered program based on principles taught in the Holy Bible. Are you willing to learn and adhere to these principles?*

YesNo

What activities or programs are you currently participating in to support your physical, spiritual, and emotional needs?*

Do you have a sponsor? (We reserve the right to contact your sponsor)*

YesNo

Sponsor Name

First NameLast Name

Sponsor Phone Number (We reserve the right to contact your sponsor)

Please enter a valid phone number.

What is the best time for you to be interviewed?*

What is the best way to contact you?*

What do you hope to accomplish by participating in The Oaks Ministry Program?*

Where did you hear about The Oaks Ministry?*

Name of Personal Referral:

First NameLast Name

I, the named below individual, desire to enter The Oaks Ministry Residential Program.

First NameLast Name

The Oaks Ministry Residential Program is a Christian Discipleship Training Program. I have made a commitment to Jesus Christ, or I am willing to consider the possibility of doing so. People who enter The Oaks Ministry Residential Program may have had histories including, but not necessarily limited to, drug and alcohol abuse, and/or mental or emotional problems. The Oaks Ministry Residential Program is not licensed by the State of Pennsylvania as a Drug and Alcohol Treatment Program or as a Mental Health Facility. The program offered by the Oaks Ministry team consists of Bible-based teaching with spiritual emphasis.

Any false statements or answers on this application may be subject to denial or admission into, or, dismissal from The Oaks Ministry Residential Program.

Date

Email

example@example.com

Completed forms may also be submitted to The Oaks Ministry Housing Program, 290 Bethel Road, Oxford PA 19393

The Oaks Ministry Housing Program Application

Personal Information