FreedomWorks
P.O. Box11175
612-522-9007
FreedomWorks Resident Discipleship
Application
Please read the FreedomWork=
s Resident Discipleship Covenant Agreement before you contin=
ue with
the application process. If you agree to live by the covenant agreement, please complete t=
his
application. Mail it to the above address, along with the other documents
listed at the end of this application.
FreedomWorks staff will review the application materials. An i=
nterview
with you may be requested. At the end of the review process, FreedomWorks s=
taff
will promptly send you a letter to advise you of their decision.
Please Print
Personal Information
First Name: _________________________________ Middle Name: ____________________=
_____
Last Name: _________________________________ OID #: _____________________=
_____
Date of birth: _____________=
_______Place
of birth: _____________________________________
Marital status: _____married=
_____single _____involved _____separated <=
span
style=3D'mso-spacerun:yes'> _____divorced
Number of children: ________=
___ Contact Information:
______-______-______
Criminal Histor=
y
Due to insurance restrictions, those convicted of sexual offen=
ses
and arson are not eligible to =
reside
at FreedomWorks Discipleship Apartments. You may, however, continue to apply
for all other services. All information must be filled out.
Conviction(s): _____________=
_________________________________
Date: _____/_____/_____
Conviction(s): _____________=
_________________________________
Date: _____/_____/_____
Conviction(s): _____________=
_________________________________
Date: _____/_____/_____
County of commit: __________=
_______________________City
of commit ____________________
County of parole if other th=
an
committing county: ______________________
Are you currently, or will y=
ou be
on Intensive Supervised Release? _________
Supervised Release date: ___=
_/____/______
Supervision Expiration Date: ____/____/______
Conditions of release:
_______________________________________________________________
_= ___________________________________________________________________________= _____
Case Worker’s name ______________________________________ Phone: _____-_=
_____-______
Parole Officer’s name _____________________________________ Phone:
_____-______-______
M=
edical
History
You must sign a release of medical information form prior to moving into Freedo=
mWorks.
This will allow FreedomWorks to communicate with medical personnel in case =
of
an emergency or other reason for your benefit. All information
must be filled out. *See attached
Doctor(s) name: ____________=
________________________________________________________
Name(s) of prescription(s) y=
ou are
currently taking: ________________________________________
Have you ever been treated for mental health issues? ______ please
list detailed list of past prescriptions you were prescribed for mental hea=
lth:
________________________________________
__________________________________________________________________=
________________
If yes, please list all dates, locations and the conditions you we=
re
treated for: ____________________ _________________________________________=
_________________________________________
A=
ddictions
Have you ever been addicted =
to any
form of drugs or alcohol? If yes, what types? ________________
____________________________=
______________________________________________________
Date of last drug use: _____/_____/_____ Date of last drink:
_____/_____/_____
Have you been in a drug or a=
lcohol
treatment program? ___________ When? _________-__________