Calvary House Men Residential Application | Calvary Chapel Ft Lauderdale

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Calvary House For Men

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Personal Information
Name*
First Last
Middle Nickname
Phone Number*
Email Address*
Enter Email Confirm Email
Date of Birth*
Age*
Place of Birth*
Address*
Street Address Address Line 2 City State ZIP Code
Personal Identification
Select One*
*
State*
Upload a photo of yourself
Max. file size: 50 MB.

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Emergency Contact Information
Name*
First Last
Relationship*
Phone Number*
Address*
Street Address Address Line 2 City State ZIP Code
Parents Names (If Living)
Parents' Address
Street Address City State
Are parents separated/divorced?
- Yes
- No
Is either parent deceased?
- Yes
- No
When?
Do you have siblings?
- Yes
- No
How many brothers?
How many sisters?

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Marital Status/Children
Marital Status*
- Married
- Single
- Separated
- Divorced
- Widowed
Reasons for Divorce or Separation*
Wife's Name*
Date of Birth*
Phone Number*
Wife's Address*
Street Address
Do You Have Any Children?*
- Yes
- No
Names & Ages*
Are you subject to any alimony/child support payments?*
- Yes
- No
How Much?*

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Education
Did you graduate from High School?*
- Yes
- No
Which High School?*
Did you attend college?*
- Yes
- No
What was your major?*
Degree earned*
Did you attend trade school?*
- Yes
- No
Which trade?*
Did you complete trade school?*
- Yes
- No

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Work History
Start with the most recent work history for each company/position that apply to you
Current occupation*
Years of experience in current occupation*
Company 1
Company Name
Address
Street Address City State
Phone Number
Position
Start Date
End Date
Company 2
Company Name
Address
City State
Phone Number
Position
Start Date
End Date
Company 3
Company Name
Address
City State / Province / Region
Phone Number
Position
Start Date
End Date

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Military Experience
Are you a veteran?*
- Yes
- No
Branch of Service*
Highest Rank*
Years in the service*
Discharge date*
Discharge type*
Please explain reason for discharge:*
Were you ever court-martialed?*
- Yes
- No
Please explain reason for court-martial:*

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Medical Information
What is the state of your health:*
- Excellent
- Good
- Fair
- Poor
- Declining
Height (ex: 5'10'')*
Weight (ex: 190lb)*
Usual Weight (ex: 190lb)*
Any recent weight changes?*
- Yes
- No
List all major illnesses and/or surgeries that you have or have had:*
Have you ever had a venereal disease?*
- Yes
- No
What disease?*
When did you contract the disease?*
When were you last tested for HIV?*
When were you last tested for Hepatitis C?*
When were you last tested for TB?*
Do you smoke or chew any form of tobacco (i.e. cigarettes, dip, etc)*
- Yes
- No
Are you currently taking any prescription or over the counter medication?*
- Yes
- No
Please list any medications you are currently taking:*
How long have you been taking each medication?*
Please list any side effects associated with this medication:*
Have you ever suffered from depression?*
- Yes
- No
Please describe:*
Have you ever been treated for any psychiatric illness?*
- Yes
- No
Please describe condition & treatment:*
Have you ever considered suicide?*
- Yes
- No
When?*
Have you ever attempted suicide?*
- Yes
- No
When?*
Why?*

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Alcohol/ Drug Use History
Please list any rehabilitation centers you have attended:
How many rehabilitation centers you have attended?*
- none
- 1
- 2
- 3+
Name:*
When:
Completed?*
- Yes
- No
Name:*
When:
Completed?*
- Yes
- No
Name:*
When:*
Completed?*
- Yes
- No
What is/are your drug(s) of choice?*
At what age was your first drinking/drugging experience?*
How has your drinking/drugging pattern changed to now?*
What is your longest period of sobriety in the past two years?*
When did you last drink or get high?*
What did you drink/use?*
Is there any other information about your drug or alcohol use that you wish to share?*

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Criminal History
Number of times arrested?*
- Never
- 1
- 2
- 3+
Charge:*
Date of Charge:*
Time Served:*
Charge:*
Date of Charge:*
Time Served:*
Charge:*
Date of Charge:*
Time Served:*
Have you ever been charged with any sexual crime?*
- Yes
- No
Are there any charges pending against you at this time?*
- Yes
- No
Court Date:*
Are you currently on probation/parole?*
- Yes
- No
For how long?*
Name of Probation/Parole Officer:*
Phone Number*

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Spiritual Background
What is your church affiliation?*
How often do you read the Bible?*
How often do you pray?*
Are you saved?*
- Yes
- No
- Not sure
When?*
Briefly describe your testimony and your walk with Christ since that time:*
Personal References
Please provide 3 personal character references (at least one from a pastor or church staff)
Reference #1
Name*
First
Relationship*
Phone Number*
Reference #2
Name*
First
Relationship*
Phone Number*
Reference #3
Name*
First
Relationship*
Phone Number*

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