Application Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Phone Number *Email *Date of Birth *HeightFormat Example: 5' 11"WeightT-Shirt Size *Marital Status *Number of Children *Emergency Contact *FirstLastEmergency Contact Address *Emergency Contact Phone Number *Relationship With Emergency Contact *Lawyer's Contact Information *How did you hear about the ministry? *What are your life controlling issues? (i.e. drugs, alcohol, sex, gambling, etc.) *What drugs are you currently struggling with? *When's the last time you've used and what was it? *Have you had any previous treatments or attended programs for these issues? If yes, provide the name of the facility that you left. *If you are incarcerated, please list your charges and/or convictions. *Do you have any pending court cases or legal issues? If so, please explain. *Are you a registered sex offender? If so, please explain and include any restrictions you may have. *Have you been convicted of any violent crimes? If so, please explain. *Do you have any diagnosed medical conditions? If so, please explain. *Have you been diagnosed with any mental health disorders (bipolar, schizophrenia, etc.)? If so, do you take an medications and what are their names? *Are you currently taking any prescribed medications? If so, please explain and list ALL of the medications.How do you plan on paying for you medications while at A Better Way? *Are you able to perform manual labor? *Do you have any physical limitations? If so, please explain. *Are you a Christian? If so, how long and what denomination? *If you are not a Christian, do you identify with any other religion or belief system? (not being a Christian does not disqualify you) *Can you read/write in English? *What grade did you finish in school? *Are you willing to complete 18 months or more at staff discretion? *Are you willing to be mandated by the courts? *Tell us who you admire most in life and why, what has been your most pivotal life experience, and what do you hope to accomplish at A Better Way. *CommentSubmit