The Potter's House Application Pt 1

By checking this box I am acknowledging that I have read The Potter's House Handbook and I am willing to follow it's guidelines.

Yes

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Birthdate

Marital Status

Primary/Emergency Contact Name

Primary/Emergency Contact Phone #

Relationship to Primary/Emergency Contact

Please share any details surrounding your relationship status that might be relevant.

Please list names and ages of your children

Please provide contact info and details about who will be caring for your children and/or custody information.

EDUCATION HISTORY

Level of Education attempted/completed

Please note any trade school or specialty training you have completed/attmepted.

WORK HISTORY

Please provide information about your work history.

Please provide a brief work history.

Please share any additional skills you may have. For example, sewing, cooking, gardening etc.

LEGAL

If you have any current legal matters pending, please describe charges, list courts, case numbers and court dates.

Do you have an active warrant for your arrest?

Yes

No

Have you spent time in jail or prison?

Yes

No

Are you currently on parole or probation?

Yes

No

If yes, please describe conditions of your probation and PO contact info.

Are you willing to allow The Potter's House to run a background check?

Yes

No

MEDICAL

Insurance:

Do you currently have medical insurance?

Yes

No

If no, who will be responsible for medical/dental bills incurred while in ministry? (Name & Phone #)

Insurance Agency & Policy #

History:

Please list any current/previous medical conditions. Include diagnoses, diseases, surgeries, and psychiatric illnesses.

Do you have any physical limitations?

Yes

No

If yes, please explain

Do you smoke or use any form of tobacco?

Yes

No

Have you ever been in a mental institution/psych ward?

Yes

No

MEDICATIONS

Are you currently taking any RX, over the counter medications or birth control?

Yes

No

If yes, Please list ALL medications you are taking, include dosage, Rx Number and how long you have been taking each one.

List any dietary restrictions:

SPIRITUAL BACKGROUND

Are you affiliated with a church/denomination?

Yes

No

Is a church or pastor currently assisting you?

Yes

No

If yes, please provide contact information (Name & Phone #)

Yes

No

Are you a born again believer?

Yes

No

Please describe church history and your relationship with the Lord. Include church attendance, bible reading, prayer time, fellowship, period of backsliding, etc.

Date Input

Signature