Mt. Zion House Application

Date of Application ____-____-_____

Name___________________ Address_____________________City_____________
State________Phone#____________________Date of Birth____________________
Place of Birth - City____________________State_______Height_______Race______
Hair color_________Eye color_________Tattoos____If yes, describe tattoo________
___________________________________________________________________

Social Security #______-______-______ Must have a SS card and valid state picture ID
Drivers license#____________________ Expiration date_______ State____________

Physical disabilities or defects? yes___ no___ If yes, explain______________________
___________________________________________________________________
How would you rate your condition of health? poor______fair______good__________
Are you taking any prescription drugs or medication?________If yes, What drugs and
for what purpose?_____________________________________________________
What drugs are you taking that are nonprescription?_____________________________
Have you ever been tested for AIDS?_____Are you HIV positive?____Not sure?_____
Have you been tested for Hepatitis A,B or C?____________Are you Hepatitis A,B or C
positive?__________Not Sure?_________
Are you currently under the care of a physician?______A psychiatrist?______If yes, have
you ever been diagnosed with a mental illness?_______If yes, what illness?___________

Military service yes____ no____ If yes, which branch___________How long_________
Last grade completed in school?__________ List job skills _______________________
____________________________________________________________________

Have you ever been arrested?_____How many times?________ Give dates and what for,
be specific - __________________________________________________________
Have you ever spent time in jail or prison?_____ How long and where?______________
____________________________________________________________________
Have you ever assaulted anyone?______If yes, were you under the influence of drugs or
alcohol?______________ Have you ever committed murder?__________Have you ever
molested a child?______If yes, male or female?________ How old was the child?_____
How old were you?_____How many times?_____Have you ever raped anyone?_____
Do you have any warrants for your arrest?________What for?____________________

Have you ever thought about suicide?______ Have you ever attempted suicide?_______
If yes, by what means did you try, and how many times?_________________________

Are you homosexual?____ Are you bisexual?_____ Is anger a problem with you?______
Have you ever been divorced?____ Are you in debt?_____How much?_____________

Are you a drug addict?____What is your drug of choice?_______________Are you an
alcoholic?_____Do you consider yourself addicted or attracted to pornography?_______

What is your religion of choice?_______ Do you go to church?______
Who do you say Jesus is?_______________ Do you pray?______ How often?_______
Do you believe in God?_____ Do you read the Bible?______ How often?___________
Are you saved?_____ How long?________ Have you been baptized in water?________
When?______________Have you been baptized in the Holy Spirit?________________
Not sure?________

Explain why you want to be admitted into Mt. Zion House.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Contact Person_______________ Phone_____-_____-___________
Fathers name_________________ Address__________________________________
Phone number____ -______-_____________
Mothers name________________ Address__________________________________
Phone number_____-______-____________
Wife ______________________ Address___________________________________
Phone number_____-_____-________
Children's names_______________________________________________________
Who has custody of children?_____________________________________________
Siblings names________________________________________________________

Do you understand and accept that we use only the Word of God for all Teachings,
counseling, and instructing? And that this program is Christian based? yes___no____
Is all the information that you gave true to the best of your knowledge?___________
The Bible says that you shall know the Truth and the Truth shall set you Free and
you will be free indeed. Are you ready to be set Free?___________
I agree that by signing this application, I am making a 26 week commitment to Mt. Zion
House. I understand that I must be faithful in all that is required of me in order to graduate
the program. I agree to abide by all the rules of Mt. Zion House..

Student's signature___________________________

Director's signature____________________________
Date_____-______-________