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SAVE A LIFE MINISTRIES, INC

Program Admissions
Application
Please complete and email or mail a copy of this form to:
Save A Life Ministries, Inc.
Attn: Project Manager
c/o Summers Cottage
1315 S. 3rd St. Ozark, MO 65721
Phone (417) 581-0853
[email protected]
12/15/2013

Document is the application for the admission into one of Save A Life Ministries, Inc specific
community outreach project programs. All information must be included before application can
be reviewed and processed. Please fill out entirely and return to the above physical or email
address. If assistance is needed, please call the phone number listed above.

Application for Program Entry

For Office Use
Only:

Date:____________________

Personal Information
Last Name___________________________ First_________________________ MI_______________
Street Address_________________________________

Home Phone ( )_______-_______________

City, State, Zip_________________________________

Cell Phone ( )________ -_______________

How long at present address? _________ Years ________ Months

What was your previous address?________________________________________________________
How long at previous address? _________ Years ________ Months
Email Address:
Drivers License#

State

Date of Birth ______________________________

(2 forms of verification required)

Exp. Date

Any Violations?

Y / N

Social Security No._______-_____-_______

Babys Name, Date of Birth or Due Date___________________________________

Male / Female

How did you learn of our Ministry?_______________________________________________________

Are you involved in any civil cases involving DFS or any other government agency?
Y / N
If yes, explain and list any case workers___________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________
__________________________________________________________________________________
Are you legally eligible for employment in the United States?
Are you employed now? Y / N

Y / N

If so, may we inquire of your present employer? Y / N

Have you been convicted of a crime in the past 5 years, including misdemeanors and summary offenses,
which has not been annulled, expunged or sealed by a court?
Y / N
If Yes, describe in full._________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________
Are there any reasons for which you might not be able to perform the job and/or household duties (with
a reasonable accommodation)? Y / N If Yes, please explain.____________________________

Familial Background
Mothers Name __________________________________________ Phone (
)________________
Address____________________________________________________________________________
Fathers Name ___________________________________________ Phone (
)________________
Address____________________________________________________________________________
Are they married? Y / N If so, how long? ___________________
If not, were they ever? Y / N
Have either parent remarried? Y / N
Do you have relationships with both parents? Y / N
How many siblings do you have and where do you fall in the order? ____________________________
Do you have a relationship with the father of your baby? Y / N
Does he have any legal visitation or
joint custody? Y / N _________________________________________________________________
Does your family have a religious preference? Y / N If so, are you a member or do you attend
church and where? ____________________________________________________________________
Has anyone in your immediate family ever been involved with a recovery program of any kind? Y / N
If so, what kind and where? ____________________________________________________________
Health History
Have you ever been diagnosed with any type of disease requiring continued medical treatment and/or
medication? Y / N If so, explain______________________________________________________
__________________________________________________________________________________
Are you currently taking any medications? Y / N If yes, explain_____________________________
__________________________________________________________________________________

Do you have any allergies? Y / N If yes, explain__________________________________________

___________________________________________________________________________________
Do you smoke? Y / N If yes, how much and how long have you been smoking? ________________
___________________________________________________________________________________
Do you drink alcohol? Y / N If yes, how much and how often? ______________________________
___________________________________________________________________________________
Do you or have you ever used illegal drugs, prescriptions that do not belong to you or over the counter
medications in a way they were not intended? Y / N If yes, what, how much and how often? ______
___________________________________________________________________________________
___________________________________________________________________________________
Have you ever experienced depression? Y / N If yes, have you ever thought about or attempted
suicide? Y / N If yes, how and when?__________________________________________________
__________________________________________________________________________________
Do you now or have you ever struggled with an eating disorder? Y / N If yes, what type and how long
ago?__________________________________________________________________________
Do you now or have you ever struggled with cutting or any other form of self mutilation? Y / N
If yes, what type and how long ago? _____________________________________________________
__________________________________________________________________________________
Are you now or have you ever been involved in an abusive relationship? Y / N If yes, from whom,
what type and how long ago? __________________________________________________________
__________________________________________________________________________________
Do you now or have you ever filed an ex parte against your abuser? Y / N If yes, against whom, is it
current and how long ago?_____________________________________________________________
__________________________________________________________________________________
Education
Current or most recent school name and location ____________________________________________
What grade have you completed? 7 / 8 / 9 / 10 / 11 / other ______________________________
Employment History Please give accurate, complete full-time and part-time employment
record. Start with present or most recent employer.

1. Company Name ___________________________________

Telephone (

) _____ - _______

Address ___________________________________________

Employed From ______ To ______

Name of Supervisor__________________________________

Hourly Rate __________________

Job Title and Duty Description:_________________________________________________________

Describe Your Work Reason for Leaving__________________________________________________
___________________________________________________________________________________
2. Company Name ___________________________________

Telephone (

) _____ - _______

Address ___________________________________________

Employed From ______ To ______

Name of Supervisor__________________________________

Hourly Rate __________________

Job Title and Duty Description:_________________________________________________________

Describe Your Work Reason for Leaving__________________________________________________
___________________________________________________________________________________
3. Company Name ___________________________________

Telephone (

) _____ - _______

Address ___________________________________________

Employed From ______ To ______

Name of Supervisor__________________________________

Hourly Rate __________________

Job Title and Duty Description:_________________________________________________________

Describe Your Work Reason for Leaving__________________________________________________
___________________________________________________________________________________

References: Give below the names of three persons not related to you, whom you have known at
least one year.
Name

Phone #

Relationship

Years Acquainted

1.__________________________________________________________________________________
2.__________________________________________________________________________________
3.__________________________________________________________________________________

The information provided in this Application for Program Acceptance, is true, correct and complete. Any
misstatements or omissions of fact on this application may result in my rejection and dismissal. I
understand that acceptance into Save A Life Ministries, Inc program does not create a contractual
obligation upon the ministry to continue to assist me in the future.
If you decide to engage an investigative consumer reporting agency to report on my credit and personal
history, I authorize you to do so. If a negative report is obtained interfering with my acceptance into the
program you must provide, at my request, the name and address of the agency so I may obtain from
them the nature and substance of the information contained in the report.

___________________ ______________________________________________________________________________
Date
Signature