Redeeming Love Home Application
Personal Information
Last Name:
First Name:
Middle Name:
Nickname:
Phone Number:
Email Address:
Date of Birth:
Age:
Place of Birth:
Address:
City:
State:
Zip Code:
Personal Identification
Drivers License Number:
State:
or
State ID Number:
State:
Emergency Contact Information
Name:
Relationship:
Phone:
Address:
City:
State:
Zip Code:
Parents Names (If living):
Parents' Address:
Are Parents Separated/Divorced?
Yes
No
Is either parent deceased?
Yes
No
When?
How many brothers do you have?
Sisters?
Marital Status / Children
Marital Status
Married
Single
Separated
Divorced
Widowed
Reasons for divorce or separation:
Husband's Name:
Date of Birth:
Phone #:
Husband's Address:
Do you have any children?
Yes
No
Where are they?
Names & Ages:
Are you subject to any alimony/child support payments?
Yes
No
How much?
Education
Did you graduate from high school?
Yes
No
Which one?
Year:
Did you attend college?
Yes
No
What was your major?
Degree earned:
Did you attend trade school?
Yes
No
What trade?
Did you complete?
Yes
No
Work History
Usual Occupation:
Years experience:
Last three employers:
1
Company name:
City, State & Phone #:
Position:
Start Date:
End Date:
2
Company name:
City, State & Phone #:
Position:
Start Date:
End Date:
3
Company name:
City, State & Phone #:
Position:
Start Date:
End Date:
Are you currently working?
Yes
No
Why Not?
Number of jobs in the last 5 years:
Preferred type of work:
Military Experience
Are you a veteran?
Yes
No
Branch of Service:
Highest Rank:
Years in the service?
Discharge Date:
Discharge type:
Please select...
honorable discharge
general discharge (under honorable conditions)
general (under other than honorable conditions)
bad conduct discharge
dishonorable discharge
Please explain reason for discharge:
Were you ever court-martialed?
Yes
No
Please explain reason for court-martial:
Medical Information
What is the state of your health:
Excellent
Good
Fair
Poor
Declining
Height:
Weight:
Usual weight:
Any recent weight changes?
Yes
No
List all major illnesses and/or surgeries that you have or have had
List any allergies that you have, or have had
Have you ever had a venereal disease?
Yes
No
What?
When?
When were you last tested for HIV?
Hepatitis C?
TB?
Do you smoke or chew any form of tobacco (i.e. cigarettes, dip, etc)
Yes
No
Are you currently taking any prescription or over the counter medication?
Yes
No
What?
How long have you been taking it?
Please list any side effects associated with this medication:
Have you ever suffered from depression?
Yes
No
Please describe:
Have you ever been treated for any psychiatric illness?
Yes
No
Please describe condition and treatment:
Have you ever considered suicide?
Yes
No
When?
Have you ever attempted suicide?
Yes
No
When?
Why?
Alcohol / Drug Use History
Please list any rehabilitation centers you have attended:
Name:
When?
Completed?
Yes
No
What is your drug(s) of choice?
At what age was your first drinking/drugging experience?
How has your drinking/drugging pattern changed to now?
What is your longest period of sobriety in the past two years?
When did you last drink or get high?
What did you drink/use?
Is there any other information about your drug or alcohol use that you wish to share?
Criminal History
Number of times arrested?
Please list from newest to oldest all charges, date of arrest, and time served for each:
Charge:
Date of charge:
Time served:
Have you ever been charged with any sexual crime?
Yes
No
Are there any charges pending against you at this time?
Yes
No
Court date:
Are you currently on probation/parole?
Yes
No
For how long?
Personal References
Please provide 3 personal character references (at least one from a pastor or church staff)
Name
Relationship:
Phone #:
Name
Relationship:
Name
Relationship:
Phone #:
Name of Probation/Parole Officer:
Phone #
Spiritual Background
What is your church affiliation?
How often do you read the Bible?
How often do you pray?
Are you saved?
Yes
No
When?
What experiences in your life have brought you to the decision to apply for Redeeming Love Home?
Briefly describe your testimony and your walk with Christ since that time:
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