Date and time

Month

Day

Year

Time

HoursMinutes

First name

Last name

Birthday

Month

Day

Year

Social Security Number

Driver's License Number or state ID

Address

Phone

Marital Status

Single

Married

Divorced

Widowed

Do you have Children

Yes

No

If yes what are their ages

Who do they live with?

Do you have parental rights?

Yes

No

Will your family participate in your recovery?

Yes

No

List any Individuals to be contacted in case of emergency. Name and phone number.

Who is Jesus to you?

Substance abuse history (please answer questions truthfully.)

Do you have a history of substance abuse or addiction?

Yes

No

If yes explain

What was your drug of Choice

How often did you use?

When did you last use?

Are you an I.V. user?

Yes

No

Do you have a history of withdraws?

Yes

No

Have you been treated at a detox facility?

Yes

No

Have you been to a treatment center before?

Yes

No

If yes, where, when and did you complete it?

Have you been diagnosed with a mental health disorder?

Yes

No

If yes please explain.

Are you currently taking medication for this condition

Yes

No

Have you ever been admitted into a psychiatric facility?

Yes

No

Do you have a history of underlying medical conditions (including food allergies)?

Yes

No

If yes, please explain and list any current medications.

Are you currently on probation or parole?

Yes

No

Officer's Name

County

Phone Number

Have you ever been convicted of a violent crime?

Yes

No

Are you a registered sex offender?

Yes

No

Do you have any pending court dates?

Yes

No

If yes please list bellow.

Highest level of education

Please list 3 previous employers starting with the most recent first.

If you have any special work experience/skills please list bellow.

PLEASE READ AND CHECK THE FOLLOWING STATEMENTS IF YOU AGREE TO THAT STATEMENT.

The Woodshed is a nicotine/vape free program. We have a zero-tolerance policy concerning this issue.

I understand that I am not allowed to take any narcotics or certain medications prescribed to me that would alter my mental state. I.E. (Medication for the treatment of anxiety, depression, sleep disorders, behavioral disorders, chemical imbalance or any sort of pain medication, narcotics, or psych meds) All medications must be approved by the executive director. I am making this decision on my own accord, and I am NOT being forced in any way to stop taking prescribed medications.

I understand and agree that The Woodshed is a gospel centered transformational ministry that requires community service, class attendance, worship services, and events designated by staff. Any failure to comply with the rules and regulations specified by TheWoodshed can result in immediate dismissal from the program.

I certify that the information in this application is true and accurate to the best of my knowledge. I give permission for The Woodshed to speak freely with all legal entities and agree to a criminal background check. I consent to the search of personal propertyat any time with or without notice and random drug testing. Any violations will result in immediate dismissal, and I understand that any use or possession of drugs and/or alcohol, or disruptive behavior can and will cause dismissal

I understand also that my information/photo/etc. may be used to help promote the cause and purpose of The Woodshed.

BACKGROUND CHECK AUTHORIZATION: I hereby authorize The Woodshed and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to begenerated for employment and/or volunteer purposes. I understand that the scope of the consumer report/investigative consumerreport may include but is not limited to the following areas: verification of social security number: credit reports, current and previous residences: employment history, education background, character reference; drug testing, civil and criminal history records.

I agree to the back groud check.

Please sign only if you agree to all of the above statments.

Signature

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