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FUTURE CAMPUS
PROGRAMS
- RESIDENTIAL RECOVERY PROGRAMS
  - MEN'S RECOVERY CENTER
  - WOMEN AND CHILDREN'S CENTER
- LEADERSHIP COLLEGE
- CRISIS AND COMMUNITY CARE
- SUNDAY NIGHT CHURCH
- IGNITE STUDENT MINISTRIES
GET INVOLVED
ABOUT
EVENTS

FUTURE CAMPUS
PROGRAMS
- RESIDENTIAL RECOVERY PROGRAMS
  - MEN'S RECOVERY CENTER
  - WOMEN AND CHILDREN'S CENTER
- LEADERSHIP COLLEGE
- CRISIS AND COMMUNITY CARE
- SUNDAY NIGHT CHURCH
- IGNITE STUDENT MINISTRIES
GET INVOLVED
ABOUT
EVENTS

Leadership College Application

Basic Information

First name*

Last name*

Email*

Phone number*

Birthday*

Street address

Contact Type

City

State/Region

Postal code

Describe your current living situation.*

Are you incarcerated?*

Yes
No

Are you a U.S. Citizen?*

Yes
No

Are you experiencing homelessness?*

Yes
No

How did you hear about us?*

Family Information

Number of minor children?*

Marital Status*

Are you or is a woman currently pregnant by you?

Yes
No
Maybe

Are you involved in a violent situation?*

Yes
No

Special Needs

Do you have a disability?

Physical
Emotional/Mental
Other

Income

(You may not receive income while in the program unless you receive income for a disability or are a mother receiving assistance for your children.)

Employment Status*

Income Types*

No Financial Resources
Veteran's Benefits
Social Security
Family/Friends
General Assistance (GA)
Supplemental Security Income
Food Stamps (EBT)
Social Security Disability Income
Unemployment Benefits
Calworks
Child Support
Other

Medical Information

Do you have medical insurance?*

Yes
No

Do you have a substance abuse problem?*

Yes
No

Are you taking prescribed medications?*

Yes
No

Are you clean and sober now?*

Yes
No

Do you use tobacco/nicotine products?*

Yes
No

Education

Highest Degree Earned*

Are you going to school now?*

Legal

Please explain any open or pending matters with the court system.*

Have you ever been convicted of a felony or a misdemeanor?*

Yes
No

Do you have a court mandate to participate in a recovery program?*

Yes
No

Additional Questions

How do you think this program will help you?*

Are you currently involved in a romantic relationship?*

Please take the opportunity to let us know any other information that may be important as you apply to become a resident?*

Describe your relationship with Jesus, including how you came to know him.*

Within the College, you will be working with minors. Is there anything that would complicate or prohibit this?*

Do you currently attend a church?*

Yes
No

Powerhouse Ministries is a Christian non-profit which exists to inspire and empower people to rise above their circumstances, change their lives, and impact their community.