Jump Start Online Application Step 1 of 5 20% Please read completely BEFORE completing your application. All prospective students of the Los Angeles Mission’s Residential Life Recovery Program must meet the criteria below. Please select each box as it applies to you:A COMMITMENT TO RECOVERY*Are you willing to commit one year to your own recovery from drugs, alcohol or whatever issues you are struggling with? Yes No A COMMITMENT TO A CHRISTIAN (FAITH-BASED) PROGRAM*Are you willing to participate in classes/counseling sessions that are Christ-centered, biblically-based? Yes No PHYSICAL ABILITY*Are you capable of meeting physical fitness criteria, including daily ministry and vocational assignments, such as chores and job readiness training? A TB clearance within the past 12 months and a Medical Evaluation is required upon entering the program. Yes No MENTAL ABILITY*Are you mentally capable of participating in all aspects of the program, including attending classes and working cooperatively with the program staff? A mental health evaluation is required. If you have a diagnosis that requires medication, you will need a 30-day supply and a prescription for refills as needed. Yes No A COMMITMENT TO PROGRAM COMPLIANCE*Are you willing to comply with all program policy and procedures? Students who are accepted into the program are restricted to the premises for the first 30 days and will not be allowed to leave the building, make/receive phone calls or have visitors. Prospective students must take care of all personal business before entering the program, as you will not be allowed outside appointments during the initial 30-day phase. Additionally, students are not allowed cell phones for the first 10 months of the program. Portable electronic or any Wi-Fi devices are also not allowed. Based upon income, students are assessed a $150/mo. Occupancy Fee, payable after completion of the 30-Day Jumpstart Phase. Yes No A WILLINGNESS TO REFRAIN FROM ROMANTIC RELATIONSHIPS*Are you willing to put relationships (other than legal or common law marriages) on hold while in the program? We believe students focus better on recovery without such distractions, so we discourage romantic relationship while in the program. Yes No If you selected 'No' to any of the questions above, you will not be able to continue on to complete an application. Our program will not benefit you unless you are able to commit to your total recovery. If you accidentally made the wrong selection by clicking 'No', please go back and select 'Yes' instead. If you are not able to commit to all 6 requirements at this time, the Los Angeles Mission will be here when you are ready.If you were able to select 'Yes' for each question above, then you will be able to click the 'Next" button below to complete and submit an application for review. Upon submission of your completed application, you will be contacted to schedule an interview. Bring your ID and SS card (if available). Please note that the intake process could take up to two weeks, depending upon bed availability and staff scheduling. Personal DetailsName: Date of Birth MM slash DD slash YYYY Gender* Male Female PhoneEmail Ethnicity*CaucasianAfrican American/BlackHispanic/LatinoAsianMiddle easternPacific IslanderNative American/AlaskanOtherPlace of Birth Marital StatusSingleSeparatedMarriedDivorcedWidowed# of childrenIn Case of Emergency ContactName Relationship Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country EducationSchool - Highest Grade Completed123456789101112CollegeAA DegreeBachelors DegreeMasters DegreeOthersOccupation Last Job Location Length of Employment Programs You Have Been In (List the most recent one first)Where: Date in Date Out Completed Yes No Where: Date in Date Out Completed Yes No U.S. Military Service RecordBranch: From MM slash DD slash YYYY To MM slash DD slash YYYY Number of ArrestsMisdemeanors: Yes No Felonies: Yes No Outstanding Tickets/Warrants Yes No Outstanding Tickets/Warrants Dates & Charges:Please list the dates and charges for your outstanding tickets/warrants. One per line, please.Are you on probation: Yes No Parole: Yes No Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Are you in violation of parole? Yes No Name, Location and Phone of P.O.Do you have any upcoming appointments?Legal: Yes No Court: Yes No Medical: Yes No Explain: Are you Homeless? Yes No How long have you been homeless: Where did you stay last night? Primary reason for Homelessness?Do you receive any government benefits? Yes No what amount?G.R.Food StampsSSIWhat is your church or religious background?What problems do you want to solve while at the Los Angeles Mission? Medical InformationAre you or should you be taking any medication? Yes No Please List Do you have a 30 day supply? Yes No Have you been told by a doctor that you have any of the following conditions? High Blood Pressure Heart Problems Diabetes Asthma Thyroid Problems Seizures Stomach Problems Lung Problems Hepatitis Bone Problems Kidney Problems Back Problems Psychiatric Problems Ulcers Other If Others ExplainList any other major medical problems, previous surgeries, or conditions:Can you sleep on a top bunk? Yes No Can you climb 5 flights of stairs several times daily? Yes No ExplainPlease List below all substances used such as Tobacco, Alcohol, Crack, Marijuana, Speed, IV Drugs, PCP, Powder Cocaine or Others. Click on + sign to add moreSubstanceYears UsedFrequencyLast Used