The Way; Home Monticello Application
Online application for admission
Sign in to Google to save your progress. Learn more
Full Name *
Date of birth *
MM
/
DD
/
YYYY
Social Security Number *
Phone Number *
Email Address
Current Address
Emergency Contact
Marital Status *
Do you have Children? *
Education Level Completed *
Employment Status
Clear selection
Previous Occupations
Primary Substance(s) Used: *
Date of last use: *
MM
/
DD
/
YYYY
Have you ever attended treatment before? *
Do you have any current medical conditions? *
Please list all medications you are currently taking *
Are you currently under medical or psychiatric care? *
Are you currently on probation or parole? *
If yes, what county and who is your officer
Do you have any pending charges or court dates? *
Are you court ordered to complete a program? *
Do you identify with the Christian Faith? *
Why are you seeking recovery at this time? *
Why are you interested in a faith-based program? *
Do you have a history of violent behavior? *
Gang affiliation? *
Do you have family support? *
Are you willing to commit to a 6 month program? *
Do you Authorize The Way Home Monticello to conduct a background check in order to determine your program eligibility? *

Authorization for Background Check

I hereby authorize The Way; Home, its representatives, agents, and/or third-party screening providers, to obtain and review information regarding my criminal history, including but not limited to records from local, state, and federal law enforcement agencies, court systems, and other public or private records repositories.

This authorization includes permission to conduct background checks both prior to my acceptance into the program and at any time during my participation in the program, as deemed necessary by the ministry.

Authorization to Communicate with Law Enforcement and Court Officials

I further authorize The Way; Home to communicate with law enforcement agencies, probation/parole officers, court officials, and other relevant authorities for the purpose of verifying information, monitoring compliance, and supporting my participation in the program.

This authorization shall remain in effect during my participation in the program and, when applicable, after my completion or departure, to the extent that such communication directly relates to my involvement in the program.

Release of Liability

I hereby release, discharge, and hold harmless The Way; Home, its staff, volunteers, agents, and affiliates from any and all liability, claims, or damages arising from the collection, use, or disclosure of information obtained through this background check and related communications, provided such actions are conducted in good faith and in accordance with applicable laws.

Program Eligibility Statement

I understand and acknowledge that individuals who are registered sex offenders or who have been convicted of certain sexual offenses are not eligible to participate in this program. By signing below, I affirm that I do not fall into this category and understand that any misrepresentation may result in immediate disqualification or removal from the program.

Certification and Consent

I certify that all information provided in this form is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may result in denial of admission or dismissal from the program.

I have read and fully understand this authorization and release, and I voluntarily consent to its terms.


Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms