Name
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First Name
Last Name
A. Briefly describe your conversion experience and your present relationship with the Lord.
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B. What areas of your character are you presently seeking God to develop and/or improve?
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C. How would you describe your relationship with your family?
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D. Please describe your relationship with your church.
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E. What is your purpose for applying for this program?
F. Please describe your spiritual and/or ministry goals.
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G. How does your family/close friends feel about your plan to enroll in The Summit?
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H. Have you ever been involved in the occult? If so, please explain.
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I. Have you ever used tobacco, alcohol, or drugs? If so, how long did you use them for and how long ago was that?
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J. Have you ever had (or do you currently have) an eating disorder? If so, please explain.
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K. Please explain any diagnosis or history of a learning disability or mental illness.
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
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Email
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Social Security No.
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Employer
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Occupation & Start Date
Are you a citizen of the United States?
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Yes
No
Sex
Male
Female
Marital Status
Single
Engaged
Married
Divorced
Separated
Have you ever been convicted of a felony?
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Yes
No
If yes, please explain:
Have you been a part of another treatment, rehabilitation, or Christian mentorship program?
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Yes
No
If yes, did you complete it?
Yes
No
If no, please explain why:
Date of Last Drink
MM
DD
YYYY
Date of Last Drug Use
MM
DD
YYYY
Please list drugs, including alcohol, that you have used addictively:
How long have you been a Christian?
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Denomination
Church Name & Address
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Please list your current home church or the last church you attended regularly.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Pastor's Name
How long have you attended, or did attend, the above church?
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Does your pastor know you are sending this application?
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Yes
No
Are they in agreement with your plan?
Yes
No
If no, please explain:
Date of Birth
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MM
DD
YYYY
Please check any allergies you have had or currently have:
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Please comment on any you marked in the space below:
Please check any of the following conditions you have had or currently have:
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Please comment on any you marked in the space below:
Please check any surgery you have had or currently plan to have:
Please comment on any you marked in the space below:
Please check any of the following you have had or currently have:
Females Only
Please comment on any you marked in the space below:
Are you pregnant?
Yes
No
Other Conditions:
Special Dietary Needs:
Are you currently under doctor's care for any condition?
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Yes
No
If yes, please specify in the space below:
Are you currently taking any prescriptions?
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Yes
No
If yes, please specify in the space below:
Do you have any physical disabilities?
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Yes
No
If yes, please specify in the space below:
If you have ever been diagnosed or have a history of a learning disability or mental illness, please explain in the space below:
1. PROGRAM PARTICIPATION
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2. FINANCIAL OBLIGATIONS
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3. CONDUCT
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4. DRUG & UA POLICY
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5. WORK POLICY
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6. CURFEW & OVERNIGHTS
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7. QUIET HOURS
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8. VISITORS
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9. BEDROOM USE
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10. BATHROOM USE
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11. KITCHEN USE
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12. LIVING ROOM USE
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13. LAUNDRY AREA USE
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14. CLEANLINESS
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15. HOUSE SUPPLIES
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16. FOOD
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17. CHORES
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18. AUTOMOBILES
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19. ANIMALS
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20. CONSEQUENCES & FINES
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21. EXPULSION
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22. MOVING OUT
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CHANGES TO EXPECTATIONS & POLICIES
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RELEASE OF LIABILITY
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I/We do hereby release Envision Mission, its agents, and volunteer assistants from any liability whatsoever arising out of any injury, damage or loss which may be sustained by said person during the course of involvement with Envision Mission. Living in The Summit Discipleship Program house is by membership only. The Summit Discipleship Program does not fall under the Landlord/tenant act. This means that a resident can be voted out of the house for violation of the house rules, including but not limited to: not doing required chores, non-payment of program fees, leaving windows and doors unlocked etc. The time given to move out will be determined by the current members of the house or the owners. Violations such as using or the selling of drugs or alcohol, disruptive behavior, or possessing a weapon will result in the resident member being given 30 minutes to gather their belongings and vacate the house and premises. I have read the items in this agreement and understand that if I am accepted into The Summit Discipleship Program, I agree to the terms listed and I waive any landlord/tenant rights that I may be entitled to. I also understand that I fully and freely subject myself to the rules of The Summit Discipleship Program. I also agree to make an effort to live a faith-based lifestyle while residing at the Summit House. Also, I understand that Envision Mission is not responsible for any personal property not picked up within three days of the expelled house member vacating their room.
