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THE FIX MINISTRY ENROLLMENT APPLICATION

General Information

Current Address
Street Address
Street Address Line 2 (Optional)
City
State/Province
Zip/Postal

Facility

FACILITY INFORMATION

Address
Street Address
Street Address Line 2 (Optional)
City
State/Province
Zip/Postal

Physical Health

Doctor

PRIMARY DOCTOR INFORMATION

Address
Street Address
Street Address Line 2 (Optional)
City
State/Province
Zip/Postal

Medications

Special Needs

Dental & Vision Health

Mental Health

Psychiatrist/Psychologist

PSYCHIATRIST/PSYCHOLOGIST

Address
Street Address
Street Address Line 2 (Optional)
City
State/Province
Zip/Postal

Medications

Legal Issues

Probation Contact Info

PROBATION CONTACT INFORMATION

Probation Officer's Address
Street Address
Street Address Line 2 (Optional)
City
State/Province
Zip/Postal
If yes, please provide the information below.

Attorney Information

ATTORNEY INFORMATION

Attorney's Address
Street Address
Street Address Line 2 (Optional)
City
State/Province
Zip/Postal

Emergency Contact

Address
Street Address
Street Address Line 2 (Optional)
City
State/Province
Zip/Postal

Financial Information

$
$

Program Fee Information

An Induction Fee of $750.00 is due at the time of admission. All applicants are responsible for seeking monthly sponsorship for costs beyond what they can afford. It cost The Fix Ministry approximately $1250.00 per month to house each student. Partial scholarships may be available based on financial need. To be considered for a need-based scholarship, please complete the following information as accurately as possible.
$per month for 12 months

Check any/all of the following personal assets and income you have and list the value of each:

Assets

Assets

Assets

Assets

Assets

Assets

Certification And Agreement

By my signature below, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should an investigation disclose untruthful or misleading answers, I may be discharged from the The Fix program. Furthermore, I understand that The Fix Ministry is a Christian, faith-based program.
Please initial the following lines to indicate that you have received, read, and agree to abide by the program guidelines listed below.
Program Policies and General Information
Room and Board Fee Information
Prohibited Medication
Applicant Electronic Signature
Date