For Students, Complete the Following Information...

Application for Admittance

COURSE ENROLEMENT: ENROLLMENT METHOD:

Last Name First Name M.I.

Age D.O.B. Soc. Sec. # Rel. Status

Street Address City State Zip

Contact #1 Type Contact #2 Type

How and when did you first find out about "Daughters of Naomi?"

Spiritual History:

Can you describe how you came to be a Christian?

What background do you have in the church? (ie: denomination or belief practiced? Family members that are religious? Positive\Negative experience with church)

Describe any experience(s) with spirituality outside the church institution? (ie: fortune telling, horoscopes, ouija boards, etc.)

What do you hope to accomplish by enrollng in Daughters of Naomi?

I,  by my signature, attest to the validity of the information contained in this document. I understand, that any discrepancies or information withheld brought to the attention of Daughters of Naomi, may result in my not being accepted into the program.


Signature:  Date:

 


TELL US YOUR STORY

Family background and childhood experiences from birth to 6th grade: (focus on times you moved, change in family dynamics, any memorable event)

Family dynamics and social experiences from age 12 through 19 (focus on major events)

Family dynamics and social experiences as a young adult to present

FULL DISCLOSURE STATEMENT:

LIST ALL YOUR CHILDREN: (If you don't know the father, if you gave a child up for adoption...say so. Give an account for every live birth.)

Name Age Father Custodial Parent

Name Age Father Custodial Parent

Name Age Father Custodial Parent
 
Name Age Father Custodial Parent
 

Mark Clearly any of the following issues you have or are experiencing. Give brief description.

Divorce

Sexual\Physical\Verebal Abuse

Alcohol Abuse

Abortion

Prostitution
 
Criminal Conviction
 
Loss of a Child (death\court order)
 
Restrainging Order Against You or a Partner
 
Emotional Breakdown\Mental Health Diagnosis
 
Eating Disorder (bulimia, anorexia, overeating, other)
 

LIST HIGHEST LEVEL OF EDUCATION ATTAINED \ Degrees, Certifications or Special Occupational Skills

School Attended Certification\Degree Date\Level of Completion

School Attended Certification\Degree Date\Level of Completion

School Attended Certification\Degree Date\Level of Completion

 

LIST 2 PEOPLE WHO CAN VALIDATE YOUR DEDICATION TO THIS DECISION TO CHANGE YOUR LIFE

 

Name Contact # Relationship

 

Name Contact # Relationship

If Recommended By a Graduate Advisor, Please Choose Which One Here 

Email contact