A Ministry of REAL Change, Inc.

Entry Level Admission Application

Return to:  P. O. Box 142067, Fayetteville, GA  30214

General Information                                                                                     

 

1.          Name:  ___________________________________________________________________

                           First                                                  Middle                                                 Last

2.          Present Address:  ___________________________________________________________

                                Street                               City                              State                Zip

        Phone:  __________________________  Social Security #  _________________________

 

3.          Email address:_____________________________________

 

4.          Parents:    Mother: _______________________ Father:   ___________________________

Address: ______________________  Address:___________________________

   ______________________                ___________________________

Phone:    ______________________   Phone:  ___________________________

Email:    ______________________    Email:  ___________________________

 

5.   What is your parents’ involvement in your life at this point?  _____________________________________________________________________________

 

6.  Referred by:  ______________________________________________________________

                                Name                   Relationship                                          Phone       

 

7.  Birth date  ________   Age  ________   Sex  _______  Weight  _______  Height  _________

 

8.  Are you taking any medications ?  Yes  ____ No  ____ If so, what? _____________________

 

9.  What are your present living conditions? __________________________________________

 

10. What is your primary source of income?__________________________________________

 

11.  Last grade completed     _____  (Check one.)  GED_____  Diploma _____  Degree _____

 

12.  Served in any branch of the military?  Yes _____ No _____ Type of discharge:___________

 

13. What circumstances and/or issues are you requesting help to address?  __________________

______________________________________________________________________________________________________________________________________________________ 

___________________________________________________________________________

___________________________________________________________________________

 

 

14.  What significant changes have occurred in your life recently?  (behavior, employment, activities, relationships, etc.)  _________________________________________________________________________

      __________________________________________________________________________

      __________________________________________________________________________ 

      __________________________________________________________________________

      __________________________________________________________________________

      __________________________________________________________________________

 

15. Explain why you want to come to the Pathway Home and how hard you will work.         __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

 

  1. If accepted, when are you available to begin your commitment? ______________________________________________________________________

 

 

  1. Please attach a written summary of the story of your life in a minimum of two pages.

 

 

 

Signature:  ___________________________________     Date:  ________________________