A Pavilion Churches Ministry
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The Journey Begins
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Contract of Residency
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Home
Potter's House Blog
Find Out More
The Journey Begins
Apply Now
Contract of Residency
Donate
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YOUR CART
The Potter's House
Applicant Information
*
Indicates required field
Name
*
First
Last
Date of Birth
*
(mm/dd/yyyy)
Any prior rehab/halfway house/treatment? YES or NO
*
Please select
Yes
No
If YES, please describe.
*
Drug of choice:
*
Current medications you are prescribed:
*
Do you have a valid picture ID?
*
Please select
Yes
No
Do you have a Social Security card?
*
Please select
Yes
No
Are you currently working?
*
Please select
Yes
No
Do you have a vehicle?
*
Please select
Yes
No
Are you willing to take random drug screen and breathalyzers?
*
Please select
Yes
No
Emergency Contact Information
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Relationship to applicant
*
I have read the Potter's House "Contract of Residency" and agree to its terms:
*
Yes
No
I'm Ready!