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WHAT IS SUMMIT
DISCIPLESHIP PARTNERS
APPLICATION
Online App - APPLICANT INFO
Online App - PERSONAL HIST
Online App - FNDTNL VALUES
Online App - EXPECT & POL
MULTIPLICATION OPPORTUNITY
APPLICANT INFORMATION
*
First Name
*
Last Name
Multi-line address
*
Country/Region
*
Address
Address - line 2
*
City
*
Zip / Postal code
*
Email
Phone
Are you a citizen of the United States?
Yes
No
Occupation
Monthly Income
Start Date
Month
Month
Day
Year
Marital Status
Choose one
Have you ever been convicted of a felony?
Yes
No
If yes, please explain:
Have you ever been part of another treatment, rehabilitation, or Christian mentorship program?
Yes
No
If so, did you complete it?
Yes
No
Date of Last Drink
Date of Last Drug Use
*
Please list drugs that you have used addictively:
BACKGROUND INFORMATION
*
How long have you been a Christian?
Denomination
Pastor's Name
Church Name
Multi-line address
Country/Region
Address
City
Zip / Postal code
Phone
How long have you attended the above church?
Does your pastor know you are sending this application?
Yes
No
Are they in agreement with your plan?
Yes
No
If no, please explain why:
Occupational Skills
Other Abilities
Highest Education Level Completed
Choose one
Languages Spoken
FINCANCIAL INFORMATION
Do you have viable income for program fees ($300-$500/month)?
Yes
No
If not, what percentage of your program fees do you have now?
0%
25%
50%
75%
90%
If not, what source will your program fees come from?
Do you have any outstanding debts?
Yes
No
If yes, please explain:
EMERGENCY CONTACT
First Name
Last Name
Phone
Multi-line address
Country/Region
Address
City
Zip / Postal code
We may inform this individual that you are taking part in this program
CONFIDENTIAL HEALTH FORM
Please indicate which of the following conditions you have had or currently have. Please comment on any current conditions in the space provided below.
ALLERGIES/ADVERSE REACTION
Penicillin
Sulfonamides
Hay Fever
Food [Specify Below]
Other [Specify Below]
SURGICAL HISTORY
Appendectomy
Tonsillectomy
Hernia Repair
Cholecystectomy
Other [Specify Below]
DIGESTIVE & GASTROINTESTINAL CONDITION
Jaundice
Intestinal Troubles
Recurrent Diarrhea
Stomach/Duodenal Ulcer
Hepatitis [Specify Below]
Other [Specify Below]
KIDNEY & URINARY DISEASE
Kidney Disease
Other [Specify Below]
MUSCULOSKELETAL & JOINT CONDITION
Broken Bones
Dislocated Joint
Rheumatism
Arthritis
Other [Specify Below]
SKIN CONDITION
Scleroderma
Psoriasis
Eczema
Other [Specify Below]
RESPIRATORY CONDITION
Asthma
Emphysema
Other [Specify Below]
CARDIOVASCULAR & BLOOD
Heart Trouble
Blood Pressure - High
Blood Pressure - Low
Anemia
Other [Specify Below]
NEUROLOGICAL
Headaches
Fainting Spells
Paralysis
Head Injury
Epilepsy
Other [Specify Below]
NERVOUS SYSTEM
Parkinson's Disease
Multiple Sclerosis
Fibromyalgia
Bell's Palsy
Other [Specify Below]
ENDOCRINE & METABOLIC
Diabetes
Thyroid Disorder
Gout
Other [Specify Below]
EYE, EAR & SENSORY
Glaucoma
Color-blindness
Tinnitus
Vertigo
Other [Specify Below]
INFECTIOUS/COMMUNICABLE
Venereal Disease
COVID-19
HIV/AIDS
Mononucleosis
Shingles
Other [Specify Below]
FEMALES ONLY
Irregular Periods
Severe Cramps
Hysterectomy
FEMALES ONLY - ARE YOU PREGNANT
No
1st Trimester
2nd Trimester
3rd Trimester
CLARIFYING COMMENTS & ADDITIONAL CONCERNS
Are you now under doctor's care for any condition?
Yes
No
If yes, specify:
Are you taking any prescriptions currently?
Yes
No
If yes, specify:
Do you have any physical disabilities?
Yes
No
If yes, specify:
I CERTIFY THAT THE PROVIDED INFORMATION IS TRUE AND ACCURATE, TO THE BEST OF MY KNOWLEDGE.
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SUBMIT
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