How We Can Help

If you are or know a young man that is coming out of juvenile crime, aging out of a foster home, have run away from home,or have at-risk behavior, we can help. please fill out the form below and click "send". Pastor Larry will be in touch with you soon.

We can do the following for you:
Provide Life Skills and Independent Living Assistance
Provide Healthy and Nutritional Disciplines, Positive Outcomes
Mentoring Relationship, Fatherhood Building and Social Skills
Involvement in Community Volunteerism and Awareness
Faith-Based Spiritual Values/Coaching through Daily Chapel/Course participation

Entry Levels
1. Temporary Housing - 1-30 days (start Evaluation daily, start History daily, possibly some Training,some Outcomes documented, Follow Up discussed)
2. Mentoring Discipleship - 20-30 days (Evaluations daily, History daily, Training daily, Outcomes documented with Application, Follow up outlined)
3. Intern Mentoring Discipleship - 30 days-1 year (Evaluation weekly, History near completion to completed, Training being acquired, Outcomes documented with Application, Follow Up outlined) 4. Leadership Internship/Volunteerism - 3 years (Evaluation monthly, History completed, Training degree/certiﬁed, Outcomes documented with Application Giving back to community, Follow Up method outlined Evaluate for full time Staff)

ALL INFORMATION IS CONSIDERED CONFIDENTIAL. NONE OF YOUR PERSONAL INFORMATION WILL BE SHARED WITH ANYONE ELSE, UNDER ANY CIRCUMSTANCES. WE ALSO HAVE A NON-DESCRIMINATION POLICY. THESE QUESTIONS MAY SEEM PERSONAL, BUT THEY ARE IMPORTANT SO WE WILL KNOW YOUR CIRCUMSTANCES, AND CAN TAKE APPROPRIATE ACTION.

Name:
Email:
Address:
City:
State:
ZIP:
Phone Number:
Age:
DOB:

Father?	No Yes
Mother?	No Yes
Marital Status
Children:

Church?	No Yes
Address:
City:
State:
ZIP:
Phone Number:
Website:
Denomination:	None
What Activities Have You Been Involved In At Church?:	None

Health:	Poor Fair Good Excellent
Physical Limitations:	None
Physical Concerns:	None
Allergies:	No known allergies
Medication:	None
Tuberculosis	Never Have Now Have had
Hepatitis A	Never Have Now Have had
Hepatitis B	Never Have Now Have had
Hepatitis C	Never Have Now Have had
HIV Positive	Never Have Now Have had
Herpes	Never Have Now Have had
Veneral Disease	Never Have Now Have had
Lice	Never Have Now Have had
Can You Lift 25 LBs?	No Yes
Can climb 4 stair flights?	No Yes

Alcohol	Never Use Now Have Used
Barbiturates	Never Use Now Have Used
Cocaine	Never Use Now Have Used
Heroin	Never Use Now Have Used
Marijuana	Never Use Now Have Used
Meth	Never Use Now Have Used
Speed	Never Use Now Have Used
LSD	Never Use Now Have Used
PCP	Never Use Now Have Used
Prescription Abuse	Never Now Have Abused
Other Drugs	None

Smoking?	No Yes
Anger?	No Yes
Violence?	No Yes
Athority Conflicts?	No Yes
Homosexuality?	No Yes
Low Self-Esteem?	No Yes
Child Abuse?	No Yes
The Occult?	No Yes
Co-Dependency?	No Yes
Arrest/probation?	No Yes
Sexual Immorality?	No Yes
Pornography?	No Yes
Personal Discipline Problems?	No Yes
High School:
School Name:	None
City:
State:
Date Enrolled:	None
College:
College Name:	None
City:
State:
Date Enrolled:	None
Trade School:
Trade School Name:	None
City:
State:
Date Enrolled:	None
Have You Ever Been Dropped or Expelled From school or Treatment Program?	No Yes
If Yes, Then Why?	Not Expelled
Do You Own A Car?	No Yes
Have You Done Jail Time?	No Yes
Are You On Probation/Parole?	No Yes
Parole Officer Name:	None
Parole Officer State:
Parole Officer Phone:
Do Currently Have Pending Legal Charges, or Warrents?	No Yes

Were You Raised In A Christian Home?	No Yes
If No, Which Religion?	Leave this box alone if you selected yes above, are not sure, or were not raised in a religion.
If yes, please brefiely describe your conversion experiance	Please do not leave me empty. :)

Brefiely explain why you would like to attednd Hungry For God Home for Young Men:	Please do not leave me empty. :)
Brefiely describe your long term goals:	Please do not leave me empty. :) Tell me about your life long dream.

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