Preliminary Application For Program Entry

Very important!
Please print this out, complete the information, sign it, and mail it to us by regular mail. Be sure to include your PHONE NUMBER. Please type or print clearly. If additional space is needed, attach a separate sheet of paper and list the number of the question to which it pertains.

Download Preliminary Application For Program Entry

(FREE Adobe Acrobat Reader required)

Basic information we need from you

First name:
Middle name:
Last name:
I.D.#:	(If applicable)

Institution:	(If applicable)
Address:
City, State Zip:

E-mail:	(required)
Age:
Date of Birth:	(Example: 04/09/90)

Marital Status:	Single Widowed	Married Divorced
Contact E-Mail Address	(Required)

A few more questions to help us place you in a suitable program

1. Have you ever been in trouble with the law?	Yes No
2. For what crime(s) are you incarcerated?	(if applicable)
3. Please give your home address (Please include street address, city, state, and zip):
4. What is your expected date of release or parole? (Example: 04/09/10)	(if applicable)
5. To your knowledge, would you be allowed parole to your home county?	Yes No (if applicable)
6. Could you be paroled out-of-state?	Yes No (if applicable)

7. Please give a brief description of your religious background and experience.

8. Briefly state your educational background.

9. What are your skills?

10. What is your definition of a born-again Christian? Do you profess to be one?

11. For what reason(s) do you want to enter a Christian rehabilitation program?

12. What do you expect to gain from a Christian rehabilitation program?

13. Do any members of your family need special assistance? Please explain.

14. How did you first learn about the services of The Missing Link?

15. Please give the names and addresses of 3 persons whom we may use as character references and state their relationship to you. You may include only one relative.
a.
b.
c.
16. Are you willing to submit yourself to the rules and regulations of a Christian rehabilitation program and fully cooperate with and put yourself under the authority of its staff? Yes No

Applicant's signature:
Date:

Social worker's signature:	(or guardian's signature, if applicable)
Date:

Mail the completed and SIGNED application, along with your PHONE NUMBER, to:

Director of Placement Services
The Missing Link, Inc.
P. O. Box 40031
Cleveland, Ohio 44140-0031
U.S.A.

VERY IMPORTANT:

(1) This form MUST be completed by the person seeking help.
(2) This form MUST be SIGNED. We will not accept unsigned forms.
(3) We cannot process incomplete forms.
(4) You MUST include your phone number.
(5) ALLOW six weeks for processing BEFORE contacting us.
(6) You are responsible for contacting US for follow-up, so we know you sincerely want help.