Page 1 Page 2 Page 3 Page 4 Page 5 Phone Application for Admission Free Indeed Men’s Discipleship Ranch 23751 Meadow Lane, Perris, CA 92570Or: P. O. Box 430, Perris, CA 92572 Office (951) 943-5159 or Fax (951)943-3471 Personal Information Last Name First Name Address (yours or nearest relative) City State ZIP Phone Data of Birth Social Security Driver's License Married? YES NO Divorced? YES NO Children? YES NO Place of work Number of years there Write a short paragraph about your abuse of drugs, alcohol, life controlling problems. Legal Information Are you currently on parole or probation? YES NO Do you owe Court fines? YES NO Registered Offender Program? Drug Arson Sex Crimes Violence Medical Information Are you currently under a doctor’s care? YES NO Medications (List all life sustaining medications; by name and mg. dosage) Life sustaining meds only. Example: Heart and Blood Pressure meds. (Psychotropic medications are Not life sustaining medications) Free Indeed does not allow many Psychotropic medications in the program. Any person requesting entry into the program and currently taking Psychotropic medication must have a Step-Down Schedule prescribed by their doctor to be submitted with this application; and for any other prescribed meds that aren’t allowed here. Medications ( List Psych meds and mg. dosage) Free Indeed does not allow many Psychotropic medications in the program. Any person requesting entry into the program and currently taking Psychotropic medication must have a Step-Down Schedule prescribed by their doctor to be submitted with this application; and for any other prescribed meds that aren’t allowed here. Step-Down Schedule Step-Down Schedule Step-Down Schedule Do you have any allergies? YES NO Do you have any physical limitations that would inhibit your ability to perform manual labor? For example: A history of herniated or slipped disc in the back, hip or knee injury, neck or shoulder injuries. If so, please list here: required before admission to the program and should be submitted with this application. Please know that we are not equipped to house the disabled. “Free Indeed Ranch” is not staffed to transport guests to and from medical and dental appointments. Therefore, please take care of those problems prior to entering the ranch. Medical and dental emergencies will be taken care of promptly. Purpose My reason for making this application to the program is: What are your goals? Personal Reference Name (of someone who knows you) Phone # Known for how many years Address City State Ministry Relationship I, * understand that Free Indeed Men’s Ranch is a religious, bible based organization, a ministry of Free Indeed Christian Fellowship a church. The purpose of Free Indeed is to process new creatures in Christ into people of honor, prepared to take their place (1.) in the fellowship of believers (regular church attendance), and (2.) return to live and work, brush shoulders with the rest of the world while remaining clean and sober; meaning no alcohol, no use of drugs, and no smoking. Printed Name Date Church-Religion-Spirituality Do you attend church? YES NO Have you committed to serving Jesus? YES NO Drug Treatment I understand that Free Indeed is not licensed by the State of Calif. as a drug treatment program. Printed Name Date Note: After completely filling out this application and sending it by fax, or U. S. mail to the number—address on page 1. You are to call and make an appointment to speak with the program Director for an interview (951-943-5159). If you mail the application, please allow 3-5 days for your application to arrive before contacting us. You must call and be approved before coming into the program! During the interview prior to entry you will be asked if you have taken drugs or alcohol in the past 24 hours. Please note; that circumstances may require you to go thru a detox center before coming into the program. Important Notice It is the responsibility of the guest, or sponsor to cover travel expenses from the place of origin to Free Indeed and from Free Indeed back to the place of origin, whether they graduate or terminate the program. This is a non-tobacco use program—6 month’s I have read the above disclosure statement. I understand and agree to abide by these terms. Printed Name Date Reviewed by Director Date Agree to our terms. Agree to our terms.