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First and Last Name:
Date of Birth
Last four SS#
Email:
Phone:
Testimony: (Detailed)
Do you believe in once saved always saved?
Yes
No
Have you been baptized by water baptism?
Yes
No
Pastors Name and Church Affiliation
Why should we choose you?
Rehabilitation Name:
Graduation Date:
Counselor Name:
Do you have a State Issued ID card?
Yes
No
Do you have a Valid Drivers License?
Yes
No
Do you have fines or court cost to pay?
Yes
No
Do you owe child support?
Yes
No
Have you read our rules?
Yes
No
Will you submit to the authority of the staff of JH?
Yes
No
Are a sex offender
Yes
No
Have you answered all theses questions truthfully?
Yes
No
Thank you for contacting us.
We will get back to you as soon as possible.
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Phone: 228-669-4346
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