Ark to Peace Online Application

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Please note: This application will be used for review to determine eligibility in the Ark to Peace sober living/transitional program and does not guarantee acceptance into the program. If you are accepted into the Ark to Peace program, this application will become your permanent history. In all cases, staff and pastor confidentiality applies. (Revised April 15. 2025)

Email *

Date of this application: *

YYYY

Name of the person filling out the application: *

First and Last

Phone number of person filling out the application *

Full Name of the Applicant: *

Applicant's Address: *

Street, City, State, Zip Code

Applicant's Social Security Number: *

Applicant's Date of Birth: *

YYYY

Does Applicant consent to share confidential information: *

Yes

Does the Applicant have a driver's license: *

Yes

Applicant's Phone Number: *

What is the level of your education: *

Grade 1-6

Grade 7-9

Grade 10-12

College or Tech School

Emergency Contact Name: *

Relationship to Emergency Contact: *

Emergency Contact Address: Street, City, State, Zip *

Emergency Contact Phone Number: *

Applicant's Marital Status: *

Single

Married

Widowed

Engaged

Divorced

Does Applicant have dependent children: *

Yes

Does Applicant owe child support: *

Yes

Is child support in arrears: *

Yes

None owed

Does Applicant have health insurance: *

Yes

Is Applicant currently receiving Food Stamps: *

Yes

Has Applicant received Food Stamps in the past: *

Yes

Has Applicant been under a physician’s care in the past year: *

Yes

Does Applicant have any disabilities, illness or disease -- Answer Yes or No: *

If yes, please explain: (Please be honest)

List prescription medications currently prescribed: *

Has Applicant ever received treatment or counseling for emotional, mental, or psychological conditions: *

Yes

Has Applicant ever been diagnosed with a learning disability: *

Yes

Does Applicant have a history of seizures: *

Yes

Has Applicant ever had a severe emotional breakdown: *

Yes

Has Applicant ever attempted to commit suicide: *

Yes

Does Applicant have a history of drug abuse: *

Yes

How many years has Applicant been in addiction: *

What is the main drug used by the Applicant and how long: *

Does Applicant understand that Ark to Peace is a Christian based program: *

Yes

Does Applicant believe in the Christian God of Abraham, Isaac & Jacob: *

Yes

Does Applicant consider himself to be a Christian: *

Yes

Does Applicant have a denominational preference -- Answer Yes or No: *

If yes, please list:

Is Applicant employed -- Answer Yes or No: *

If yes, please list your employer:

Does Applicant have any obligations that would prevent a commitment to this program for 6 months or longer -- Answer Yes or No: *

Please explain:

Has Applicant ever been in a Recovery or Rehabilitation Program -- Answer Yes or No: *

If yes, name of facility and dates attended:

Is Applicant currently incarcerated: *

Yes

What is the Institution of incarceration: *

Name of the judge in Applicant's case: *

Dates of upcoming court hearings: *

Does Applicant have any felony convictions: *

Yes

What is the felony conviction: *

Does Applicant have any outstanding warrants: *

Yes

Is Applicant currently on parole or probation: *

Yes

Name of Applicant's parole officer and phone number: *

Does the Applicant have an attorney: *

Yes

Name and phone number of Applicant's attorney: *

Is Applicant on the National/State Sex Offender list: *

Yes

Signature: *

Please type your full name -- Typing your full name and submitting this application substitutes as your signature:

Submit

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