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ONLINE APPLICATION:
Online Student Application for Faith Farm Programs
Campus: Ft. Lauderdale
General Information:
Last Name
First Name
MI
Referred to
Faith Farm By
Address of Contact
City
State
Zip
Phone Number
Date of Birth
Age
Marial Status
Emergency Contact Person
Relationship
Height
Weight
Eyes
Hair
Where do you live?
Schooling Completed?
Middle School
High School
College
Select One
Do you receive government benefits?
YES
NO
Select
Describe your religious/spiritual experiences:
Substances Regularly Used:
Substance
Years Used
Last Used
Alcohol
Cocaine
Marijuana
Hallucinogens
Speed
Heroin
Other
Longest time sober in past 3 years?
in the last year?
Pattern of usage
Losses due to usage
Physical effects of abuse
Any Previous Rehabs?
YES
NO
Select
Ever been to a Faith Farm Before?
YES
NO
Select
Year:
Where:
Boynton Beach
Ft. Lauderdale
Okeechobee
Select One
Medical Information:
How would you rate your health?
Excellent
Good
Average
Poor
Select one
Are you on medications?
YES
NO
Select
Do you have a 30 day supply?
YES
NO
Select
Do you have any kind of appointment in the next 30 days?
YES
NO
Select
During the past five years have you:
Been treated for or told you have sickness or injury?
YES
NO
Select
If yes, give details:
Have you had any injuries to back?
YES
NO
Select
If yes, explain:
Do you wear glasses:
YES
NO
Select
Contact lenses:
YES
NO
Select
Constantly
YES
NO
Select
Reading only
YES
NO
Select
Do you have any bumps lesions or cuts
YES
NO
Select
Please explain:
Have you ever had any of the following:
YES
NO
Select
Arthritis or Rheumatism
YES
NO
Select
Polio
YES
NO
Select
Dizziness or Fainting spells
YES
NO
Select
Back Surgery
YES
NO
Select
Head Injury
YES
NO
Select
Diabetes
YES
NO
Select
High Blood Pressure
YES
NO
Select
Epilepsy
YES
NO
Select
Kidney or Bladder Trouble
YES
NO
Select
Asthma
YES
NO
Select
Phlebitis
YES
NO
Select
Varicose Veins
YES
NO
Select
Knee Injury
YES
NO
Select
Back Injury
YES
NO
Select
AIDS
YES
NO
Select
Loss of Hearing
YES
NO
Select
Herpes
YES
NO
Select
Loss of sight in one eye
YES
NO
Select
HIV
YES
NO
Select
Hepatitis
YES
NO
Select
Rupture
LEFT
RIGHT
Select
Which side?
YES
NO
Select
Was it operated on?
Date:
Physician:
Legal Information:
Have you ever been sued?
YES
NO
Select
Are you involved in a lawsuit?
YES
NO
Select
Date
Details:
How many Felonies have you been convicted of?
Name them:
Are you on probation?
YES
NO
Select
What County?
Probation Officers Name:
Probation Officers Phone #:
Any Court or Probation appointments in the next 30 days?
YES
NO
Select
Dates & Times
Employment History:
Employee Duties And Dates Worked:
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