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: ____________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

————————————————————————————————————————————————————————————______________________________________________________________

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:

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

What do you feel is your most serious problem?

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

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

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

What is your spiritual background?

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

What are your religious beliefs now?

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

Have you committed your life to Jesus Christ?

☐ Yes

☐ No

Date: ___/___/___

Describe your salvation experience?

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

What work skills do you currently have? (Woodworking, electrician, plumber, masonry, etc.)

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

What are your hobbies, talents, or special interests you would like to share?

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

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:________________________________________________________________________________________________________________________________________