Admission Forms – Page 3

Name *

First

Last

Date *

Why are you asking to be accepted into Hosea's House? *

Do you need to try to break a drug/alcohol/substance abuse addiction? *

Yes
No

Do you wan to learn how to live a life free of controlling substances? *

Yes
No

Have you ever been arrested or charged with a felony? *

Yes
No

If yes, please explain

Do you have a probation officer? *

Yes
No

Are you currently using illegal drugs *

Yes
No

Do you smoke cigarettes or use tobacco? *

Yes
No

Are you willing to quit smoking? *

Yes
No

Are you currently using prescription drugs in an illegal way? *

Yes
No

Do you have a problem submitting to authority? *

Yes
No

Are you willing to submit to the authority of ALL staff of Hosea's House? *

Yes
No

Do you understand that Hosea's House is a Christian discipleship program and utilizes Christian based principles? *

Yes
No

Do you understand that if you smuggle any drugs/pornography/alcohol/ anti-Christ items/unauthorized person in the house you will be automatically dismissed? *

I Understand

Are you willing to only be in contact with the people the staff approve? *

Yes
No

Are you willing to adhere to modest dress attire? *

Yes
No

Do you understand that you are required to go to Church (only Churches approved by Hosea's House) on Sunday and participate in weekly Bible study? *

I Understand

Have you ever been abused either Physically/ Emotionally/Financially/ Verbally? *

Have you ever filed an Emergency Protective Order? *

Yes
No

If yes, please explain.

Have you ever been involved with Child Protective Services? *

Yes
No

If yes, please explain

Do you understand we reserve the right to do random drug testing ? *

I Understand

Do you understand that we reserve the right to check your room & belongings at our discretion in the presence of two Hosea's House staff members? *

I Understand

Have you ever been raped? *

Yes
No

If yes, have you ever recieved therapy?

Yes
No

Have you ever had an abortion? *

Yes
No

If yes, have you ever received therapy?

Yes
No

Has anyone ever threatened you or your child/children in ANY way? *

Yes
No

Are you a Christian? *

Yes
No

Are you Born-Again? *

Yes
No

If no, what is your religious affiliation?

What recent spiritual changes have you had in your life (if any)?

Have you supported yourself in the last year? *

Yes
No

Do you owe money to anyone? *

Yes
No

If yes, how do you plan to repay them?

What areas of your life do you need help? *

Have you ever been involved in a homosexual relationship? *

Yes
No

Do you understand that Hosea's House does NOT support homosexuality? *

I Understand

Have you or your child/children ever been involved in a sex crime? *

Yes
No

If yes, please explain

What is your current job status? *

Do you understand that Hosea's House requires each resident to either work, volunteer or go to school? *

I Understand

Hobbies *

What would you like to learn if someone were willing to teach you? *

What is your trade or profession? *

How many different jobs have you held in the last year? *

What kind of specific job training have you had even if you never used it?

What kind of job or trade would you like to learn? *

Did you graduate High School? *

Yes
No

If no, did you earn your GED?

Yes
No

If yes, When?

If Month is unknown, use your best guess

List any prescription medications you have taken in the last year

Applications must be accompanied with a copy of picture ID and Social security card. A background check is required for all potential resident's. We understand that some potential resident's may have a background history. We will review each case and discuss with the potential resident at the time of interview. After the 60 day time period, Hosea's House requires each resident to pay $30.00 a week for house expenses. There is also a cost of $50.00 a week for food unless food stamps cover this cost or a hardship request has been granted by the Board of Directors. *

By signing, I agree that I have read and agree to the above.

Date *

Hosea's House Staff

Date