G

E

N

E

R

A

L

 

I

N

F

O

R

M

A

T

I

O

N

F

I

N

A

N

C

I

A

L

I

N

S

T

R

U

C

T

I

O

N

S

F

I

N

A

N

C

I

A

L

 

A

G

R

E

E

M

E

N

T

Financial Agreement

Non-refundable Registration / Administration Fee: $500.00

 

You may continue on with the online application or press the option below to return to other application options.

Return To Other Application Options Page
LP Application
You may continue on with the online application.
 Please be sure to fill in all information.
 Those field that are in bold type are masked for security purposes.
You will not be able to see what you have typed.
Continue Online Application

A

D

D

I

C

T

I

O

N

C

R

I

M

A

N

A

L

 

H

I

S

T

O

R

Y

H

E

A

L

T

H

 

I

N

F

O

R

M

A

T

I

O

N

P

E

R

S

O

N

A

L

 

M

O

T

O

V

A

T

I

O

N


 Incomplete applications will not be accepted. You may or may not be contacted again if your application is incomplete. Be sure to answer every question.
If you are accepted into the program and it is later discovered that you have provided false information on your application, disciplinary action will result up to and including termination from the program.
Although we do not charge for the program, there is a
 $500 Non-refundable Registration / Administration Fee.
This fee in no way covers the cost that this ministry incurs to house, feed, transport and do the day-to-day operations that must be done for the program to be succeed.
Lazarus Project Application

List any other mental health issues.

Full Name

Current Street Address

City

State

Zip

Home Phone (Including Area Code

Cell Phone

Email Address

Month of Birth

Day of Birth

Year of Birth

Age

Social Security Number

Gender

Race

Marital Status

Do You Have Children?

If yes, how many?

If Yes, please give names and ages.

Last level of education completed.

Who referred you to the program?

What is your relationship yo referral?

Referrals Phone Number.

Referrals email address if available.

Child Support (per month)

Alimony (per month)

Probation Fees

Court Cost

Student Loan Amount

Law Suit Amounts

Other Expense

Drivers license number?

State drivers license are issued in?

Drivers license status?

How many years have you battled substance abuse?

What is your specific drug of choice?

List all illegal drug(s) you have used in the passed.

List all alcoholic beverages you have drunk in the past.

Do you have any DUI's?

Do you currently smoke tobacco?

Do you currently use smokeless tobacco?

Have you abused prescription Medication?

If yes please list all.

Are you currently detoxed?

Have you ever been arrested?

Please give details of your arrest.

Have you been convicted of a felony or pled no contest to a felony?

Please give details of your felony conviction.

List any felony charges.

Have you spent time in prison?

If yes how many years?

How many months?

Do you currently have ant outstanding warrants for your arrest?

Are you on probation?

If yes where?

If yes who is your Probation Officer?

Please give your Probation Officer's Phone Number.

Are you a registered sex offender?

Do you have health insurance?

You will be required to take a physical exam, do you have a problem with that?

Are you willing to release the results of the physical to the Lazarus Project administrators?

Please read this section. The Lazarus Project is not responsible for any healthcare bills. That is solely your responsibility to arrange a verifiable contact person (spouse, parent, etc.) and address for healthcare professionals to send any medical bills you might incur during your residency at the Lazarus Project.

 

Your designated person will be contacted to verify that they will be responsible for any of your medical bills.

Have you read and do you understand the above statement?

Person responsible for your healthcare bills.

Person responsible for healthcare bills phone number.

Person responsible for healthcare bills address.

I wear glasses or contacts.

Caution! By pressing “Reset” you will lose all input information.

Submission to authority doesn’t even occur until you first disagree with an authority figure but agree to what he/she asks despite your disagreement.

How will you cope with the many layers of authority over you giving you daily instruction?

We have found that people battling life controlling issues only change when one of two things happens: (1) they are hurting bad enough that they have to or (2) they are hungry enough that they want to change.

In which condition are you?

List any drug rehabilitation programs that you have involved with.

Why do you want to enroll in the Lazarus Project?

The Lazarus Project is a Christ-centered, faith-based program

Why would you want to attend a Christian discipleship program?

Do you want to be free from addictive behaviors? Explain why.

Our program is very strict with stringent rules, regulations, and restrictions.

How would you deal with such a structured environment?

In addition to classroom instruction, our men perform rigorous physical labor every weekday and some weekends.

How will you cope with such a physically demanding environment?

Are you aware that the Lazarus Project is a minimum 12-month program?

I need to see eye doctor.

If yes, give Reason.

I need to see a Dentist.

If so, give reason.

Do you currently have any health issues?

HIV+ / AIDS?

Communicable Disease?

Hepatitis?

Sexually Transmitted Disease?

Completed treatment for STD?

List any other current diseases not listed above.

Do you have any current injuries?

If yes please list.

Do you have any currently allergies?

If yes please list all allergies.

List all doctor prescribed prescriptions medication.

Physicians Name

List any dietary needs.

Unless a physician instructs otherwise, you will be required to exercise your body 5 days/week at 6:00 a.m. Each morning. Like boot camp is to the Army, physical training )PT) is also important to the Lazarus Project.

Explain why or why not you would be agreeable to this exercise.

List any current physical disabilities.

Have you been diagnosed with any mental health issues?

Bi-polar.

Paranoid.

Schizophrenic.

Depression.

What makes you think you can complete a one year program?

Please provide short answers to the questions below.

By typing my name in the area below, I am certifying that all information here is accurate and true.

Application Date

This is you one chance to say anything you would like to us.

How can we be sure that you will, if accepted, fully commit to complete the 12-month program and won’t waste our time and yours?

Have you been convicted of or pled no contest to any violent crime, whether a misdemeanor of a felony?

Full Name