Central Kansas Dream Center
APPLICATION FOR ADMISSION TO THE 6-12 MONTH DISCIPLESHIP PROGRAM
Date: / /
Name:________________________________________________________________________________________________________________________________________
Phone:________________________________________________________________________________________________________________________________________
Address:________________________________________________________________________________________________________________________________________
Email:________________________________________________________________________________________________________________________________________
SS#:________________________________________________________________________________________________________________________________________
City:________________________________________________________________________________________________________________________________________
State:________________________________________________________________________________________________________________________________________
Zip:________________________________________________________________________________________________________________________________________
DOB:________________________________________________________________________________________________________________________________________
Birthplace:________________________________________________________________________________________________________________________________________
Single:☐ Married: ☐ Divorced: ☐ Widowed: ☐ Separated: ☐ Widowed ☐
Check the highest grade completed:
8th ☐ 9th ☐ 10th ☐ 11th ☐ H.S. Diploma: ☐ GED: ☐ College: ☐
Did you graduate from a Technical, Trade School or Journeyman Program?
☐ yes
☐ no
If so,please list below?
________________________________________________________________________________________________________________________________________
Have you ever been convicted of or plead guilty or no contest to a crime other than a minor traffic violation?
☐ Yes
☐ No
If yes,please describe, including the disposition of your case:
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Have you ever been accused of,investigated, or charged with any type of abuse or violence?
☐ Yes
☐ No
If yes,please explain:
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Have you ever been convicted of a sex offense?
☐ Yes
☐ No
If yes,please explain: ____________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
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Have you ever been accused of a crime involving a minor?
☐ Yes
☐ No
If yes, please explain:
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Are you now or have you ever been incarcerated?
☐ Yes
☐ No
If yes,please list DOC or current Booking Number:________________________________________________________________________________________________________________________________________
Are You currently on Parole?
☐Yes
☐ No
If so, please provide the following:
Last Name
First Name
Name of Agency
Phone #
Next of kin:
Full Name
Relationship you:
Phone #
List any kind of income source:
Income Source
$ Amount
Frequency
Do you have a valid Driver’s License?
☐ Yes
☐ No
___/__/___
State Issued
Expiration Date:
Type of DL
If CDL,List all endorsements:
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
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What do you feel is your most serious problem?
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
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Have you ever been diagnosed with any mental health issues or been in a mental hospital?
☐ Yes
☐ No
If “Yes”, please explain:
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Do you have any medical condition that would prevent your participation in strenuous physical activity or walking up three flights of stairs?
☐ Yes
☐ No
If “Yes”, please explain:
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Are you taking any type of medication?
☐ Yes
☐ No
List any type of medication:
Medication/Dosage/Frequency
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
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What is your spiritual background?
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
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What are your religious beliefs now?
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
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Have you committed your life to Jesus Christ?
☐ Yes
☐ No
Date: ___/___/___
Describe your salvation experience?
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
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What work skills do you currently have? (Woodworking, electrician, plumber, masonry, etc.)
________________________________________________________________________________________________________________________________________
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What are your hobbies, talents, or special interests you would like to share?
________________________________________________________________________________________________________________________________________
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Have you read the rules?
☐ Yes
☐ No
Note: Applicant MUST stop all use of tobacco products prior to entering the Central Kansas Dream Center.
• I understand and agree that I am under the total direction of the Central Kansas Dream Center. And that the length of my program is based solely on me and my level of commitment to change as well as the program.
Signature________________________________________________________________________________________________________________________________________
Date________________________________________________________________________________________________________________________________________
Pastor/Prison Chaplain
________________________________________________________________________________________________________________________________________
Date
________________________________________________________________________________________________________________________________________
Phone#
________________________________________________________________________________________________________________________________________
Ext:
________________________________________________________________________________________________________________________________________
/ /
Parole Officer (if applicable)
________________________________________________________________________________________________________________________________________
Date
________________________________________________________________________________________________________________________________________
Phone#
________________________________________________________________________________________________________________________________________
Ext:________________________________________________________________________________________________________________________________________
2100 Broadway Ave Great Bend, KS 67530
Email: centralksdc@gmail.com
Facebook: Central Ks Dream Center Inc
Phone: 620-282-4014
FAX : 620-307-3025
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