Pre-Application Screening

click here to download Colony of Mercy brochure

 

Name:              ___________________________________________________________

Address:          ___________________________________________________________

                        ___________________________________________________________

Email:              ___________________________________________________________

Home Phone:  _______________________ Work Phone:    _______________________

Cell Phone:      _______________________  Marital Status _______________________

 

Have you ever been a resident at the Colony of Mercy?  Yes  No

If so, when?  _________________    Did you graduate?  Yes   No

 

Please answer a few preliminary questions to help us determine your eligibility for the
Colony of Mercy Program:

1.  Are you willing and able to commit to a minimum of 120 days?  Yes   No

2.  Are you able to pay the $240.00 Application Fee?  (do not send now, to be sent with application)     Yes   No

3.  Do you have any outstanding legal matters?   Yes   No

4.  Do you have any court dates scheduled?         Yes   No  

When?  __________  For what?  ________________

5.  Do you have any court issues waiting to be scheduled?    Yes   No

6.  Have you been court-ordered to a program?    Yes   No

7.  Are you on Probation or Parole?   Yes  No    Which?  _________

Probation/Parole officers contact information 

Name _______________________  Phone __________________

8.  Is going to a program a condition of your probation?   Yes   No

 

If you answered yes to #3-8 please explain

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you physically able to work?    Yes   No

If you have work restrictions please explain:  ___________________________________

________________________________________________________________________

 

Please list ALL medications you take and for what reason:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Click here to download this form
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In His service,

the America's KESWICK Staff Family
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