COURT INFO

Are you currently or have you ever registered as a sex offender in any state?

Have you ever been convicted of a felony?

If yes, give details (when, where, what):

Do you currently have any current or pending court cases for anything?

If yes, which county?

Details:

Are you on or will you be on parole/probation/CDD?

If yes, why?

Do you have any DUI’s in the past 10 years?

MEDICAL INFO

How would you rate your health?

Are you currently under the care of a doctor?

If yes, why?

Do you have any medical conditions that would preclude you from working in an environment that requires lifting over 50 pounds or more?

If on medication, did you list on last page?

(For Women) LMP Date? 

PERSONAL INFO (CONTINUED)

Are you currently

Other: 

Driver’s License #:

State Issued:

Exp. Date

If none:

Other? Explain:

Marital Status:

Children?

Ages:

Do you currently have any CPS cases?

If yes, which county:

EDUCATION

FINANCIAL AND INSURANCE INFO

Are you receiving financial assistance?

If yes, how much per month?

What is the source?

Do you receive EBT? 

Do you have health insurance?

If yes, name provider:

SUBSTANCE ABUSE HISTORY

Do you have a substance abuse problem?

Substance(s):

Do you have problems sleeping?

Do you currently suffer from visual hallucinations?

Do you currently suffer from auditory hallucinations or hear voices?

Depression?

Anxiety? 

Have you ever been diagnosed with a mental illness?

If yes, what was the diagnosis?

When is the last time you were under care for mental illness?

Do you know or have you known anyone that was in The Bridge Program?

If yes, what’s your relationship to them?

Have you previously applied with us?

Have you been in any other programs?

If yes, list program name(s) and location(s):

FAITH BACKGROUND

Church affiliation:

Denomination preference:

What would you like us to know about you?

If you are currently incarcerated and are applying for Bridge residency, please fill out the following section:

Time in custody:

Estimated release date:

Parole board hearing date:

ID#:

Institution:

Housing location:

City:

State:

Zip code:

ALL APPLICANTS

Please read and initial the following statements:

I understand that The Bridge is a minimum 12-month program. (Initials)

I understand that The Bridge is a non-smoking/vaping program. (Initials)

I understand that there are no new romantic relationships while in The Bridge program. (Initials)

I understand that The Bridge is a working program. (Initials)

I understand that I will not be paid in the Bridge’s working program. (Initials)

I understand that there is an initial 45-day minimum blackout period. (Initials)

I understand that worker’s phase begins after month 10 at the program and milestones met. (Initials)

I understand that I cannot have a 290 registration in my background. (Initials)

To the best of my knowledge, I have no outstanding court cases in any other county. (Initials)

To the best of my knowledge, I have no outstanding CPS cases. (Initials)

I acknowledge that I have read and understand the program policies listed above. (Initials)

MEMORANDUM OF UNDERSTANDING

I understand that The Bridge Restoration Ministry (TBRM) is a charitable, Christian organization, dedicated solely to the spiritual regeneration of persons, such as myself, who are in need of assistance in their spiritual, social, and physical rehabilitation. I recognize my need for assistance, and herby apply for admission to TBRM.

I understand that, upon entry into the program, I am responsible for the payment to TBRM of a one-time program administration fee of $500. Thereafter, upon entering Worker’s Phase of the program, in which I gain employment and income, I agree to pay TBRM a program fee of $500 for each month I remain in the program with employment, until the total program fee of $1,000 is satisfied. The total financial obligation I am agreeing to satisfy is, therefore, $1,500 for the entire 12-month program.

I understand that this is a 12-month (minimum) program, and I agree to commit myself to the 12 months required. At the end of 12 months, I will be evaluated by the Executive Director to determine if more discipleship training is needed. During the course of the 12 months, if I should leave the program and then return, my program may start over, as determined by the Executive Director.

I authorize investigation of all statements contained in this application as may be necessary for the Executive Director to make a decision concerning my acceptance into the program. In the event I am accepted, I understand that should any false or misleading information given in my application, or in my interview, come to light, my discharge from the program may result.

I acknowledge and agree that while at TBRM, I am not an employee and, therefore, not entitled to any form of wages, benefits, or compensation. I also understand that, as a part of TBRM recovery program, there is a vocational training stage, the purpose of which is to teach basic life skills which will be of benefit to me in obtaining and maintaining a job (after my time in the
program). There are no wages, benefits, or compensation paid to me by TBRM in this vocational training.

I agree to allow TBRM to use photographs of me in any of its publications.

As a condition of my admission, I agree to regularly attend services and Bible classes as arranged for or conducted by the ministry.

I further agree to abide by all of the program’s rules, regulations, and guidelines and any such that may be adopted during my residence at TBRM.

Upon entering the Worker’s Phase of the program, in which I gain employment and income, I agree to pay TBRM a program fee of $500 for each month that I remain in the program with
employment.

The information I have finished above is true and correct. I further acknowledge and agree that, if I am on parole or probation, all aspects of my participation at The Bridge may be disclosed to my parole/probation officer.

I have read the Memorandum of Understanding and understand the rules and regulations of The Bridge Restoration Ministry, and agree to abide by them.

Print Name:

Signature:

Date:

All sections must be completed.

Any false, incomplete, or misleading information provided above, or subsequently, may result in termination from The Bridge Rehabilitation program.

AFTER you have filled out the application, the next step is to call (831) 372-2033 and schedule an interview. We look forward to hearing from you.

DO NOT call the Executive director’s cell phone to make an appointment.

Please not he will only answer scheduled calls Monday-Thursday between 8am-4pm.