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Campus Life Application
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Email
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Full Name
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Birthday
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Are you married?
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No
Divorced
Widowed
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If yes, what is your spouses name?
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Do you have any children?
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No
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If yes, please list their name, age, and if you owe or pay child support.
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Please list any allergies and/or medical conditions below.
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Please list any medications you are currently subscribed and what they are for.
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Please list your physicians name and phone number below.
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Please list your emergency contact below by name, phone number, and relation to you.
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Are you on probation or parole?
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No
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If yes, please provide the name and number of your probation or parole officer.
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Are there any warrants against you at this time?
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No
Maybe
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Are you a listed sex offender?
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No
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Do you have any legal issues at this time?
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No
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If yes, please explain
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Do you feel you are addicted to a drug, drugs, alcohol, tobacco, or any other life controlling problems?
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If yes, please list
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Do you have any sexually transmitted diseases?
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No
Maybe
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If yes, please list
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Are you willing to take a drug test, STD test, and/ or any other test that would insure the safety of the residence and this community?
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No
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Does your spouse (if you have one) use drugs, tobacco, and/ or alcohol?
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No
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If yes, please explain
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Are you on the run from anyone at this time?
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No
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If yes, who and why?
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Do you have a specific religion or denomination, if so, please explain.
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List any hobbies and/or activities your enjoy.
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In your own words, name the three main struggles you face and how you anticipate we will help here at Free At Last Ministries.
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