

NOTE: This application will be considered incomplete and rejected unless accompanied by a complete financial statement, job history, family lineage, and current medical report from your doctor.
Do you have 2 parents? ___ Yes ___ No
Is one male and the other female? ___ Yes ___ No
If Not, explain:__________________________________________
Are your parents married? ____ Yes ___ No
Number of years they have been married _______
If less than your age, explain ______________________________________________
Where do you live?
Do you own or have access to:
a van? ___ Yes ___ No
a truck with oversized tires? ___ Yes ___ No
a waterbed? ___ Yes ___ No
Do you have:
a tattoo? ___ Yes ___ No
an earring, nose ring or any other piercing? ___ Yes ___ No
(pierced tongue, pierced nipples or an ear gauge?)
Do you:
Use tobacco? ___ Yes ___ No
Smoke weed? ___ Yes ___ No
Drink alcohol? ___ Yes ___ No
Huff? ___ Yes ___ No
Take drugs? ___ Yes ___ No
Have sex regularly? ___ Yes ___ No
NOTE: IF YOU ANSWERED ‘YES’ TO ANY OF THE ABOVE QUESTIONS, YOU MAY DISCONTINUE YOUR APPLICATION AND LEAVE PREMISES QUICKLY AND IMMEDIATELY.
Describe in 50 words or less, what ‘LATE’ means to you. ____________________________________________________________________________________________________________________________________________________
Describe in 50 words or less, what ‘DON’T TOUCH MY DAUGHTER’ means to you.
____________________________________________________________________________________________________________________________________________________
Describe in 50 words or less, what ‘ABSTINENCE’ means to you.
____________________________________________________________________________________________________________________________________________________
Church you attend ______________________________________________________
How often do you attend? ______________________________________________________
When would be the best time to meet your:
father? _____________
mother? _____________
doctor? _____________
Youth minister?____________
teachers?_______________
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