Harvest House Application Form

Harvest House Application Form

For more information visit our website at: www.harvestoutreach.faith
Full Name*

First NameLast Name
D.O.C. Number
Gender*
Birth Date*

MonthDayYear
Phone Number
Marital Satus (Please Check one)*

MarriedDivorcedSeperatedSingle
Present Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this address a...?*

D.O.CTreatmentOther
Are you Employed?*

YesNoDisablity
Employer
Monthly Income*
Income next Month*

Legal
Have you been Convicted of a Felony?*

YesNo
If "Yes" Please List
May we do a background check and/or contact your probation & Parole Officer*

YesNo
Name and Phone Number of Probation & Parole Officer

Emergency Contacts
Emergency Phone Numbers : Include Name, the relationship to you, and phone number*

Housing and Housing Rules and Regulations
Date seeking to move in*

MonthDayYear
A Non-Refundable Sobriety Deposit of $360.00 is required to cover first months living expenses. Do you have the first months deposit?*
Must be paid before move in
I realize that the Harvest House in which I am applying for residency is under Harvest Outreach and is a Christ Centered Housing and if I chose to seek residence I must follow Harvest Outreach's Mission and Rules, and can be exited if infractions occur. (1) I understand that submiting this form for residency says that I understand The Harvest House is Christ Centered and I have a choice not to seek membership into said House. (2) I understand The Harvest House is sober living and the use of drugs or alcohol can/wil be a reason to be exited from the House and my probation/parole officer will be notified. (3) I understand that the submition of this form is saying I agree to follow The Rules (written or unwritten) of the Harvest House and Harvest Outreach(4) I understand this form does not guarantee admittance into The Harvest House*

I agreeI do not agree
Use this space for any additional information
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