Application for Membership in Rejoice House
To become a resident in a Rejoice House you must schedule an interview with our office, call
(361) 371-1416 and bring in this completed application form.
Print Name (First, Middle, Last) | Date of Birth (Month/Day/Year) |
Present Address or Treatment Facility: _______________________________________ | Your phone no:_______________________
Family member phone no.: (relationship):_______________________ Doctor phone no: |
Date of last drink? (Month/Day/Year) | Date of last drug use? (Month/Day/Year) |
Are you still struggling with any addictions? | List drugs you used actively: _________________ |
Did you read our program and house rules and are you willing to follow our program? | Are you born again? Did you repent of your sins and are determined to follow Jesus Christ? |
Are you getting welfare or other non-job related income?____________________________ If yes, how much do you receive monthly? | Marital Status: mark with X __Married __Separated __Divorced __Never married |
Are you currently employed? If yes, who is your employer and what is your monthly income? _____________________________________ _____________________________________ $_____________monthly | Do you use any prescription drugs? __________ |
______________________________________ | Date of move in? ___________________ |
I have read all program requirements and house rules as posted at http://www.rejoicecorpus.org. I understand that I can get immediately evicted if I don’t follow these rules or if I don’t get a job within 2 weeks. I am willing to participate in this faith-based program.
SIGNATURE:___________________________________ DATE:___________________________