Abba House Middle Georgia Program Application

Abba House Middle Georgia Program Application

Due to the nature of our ministry, it is our policy to not admit clients who have been convicted of violent crimes, sexual crimes or crimes against children or the elderly.
Your Personal Information Section
Today's Date *

Month Day Year
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First Name *
Middle Name or Initial
Last Name *
Your Date of Birth *

Address *

Primary Emergency Contact's Address *

Secondary Emergency Contact's Address *

Secondary Emergency Contact's Phone Number *

Area Code Phone Number
Secondary Emergency Contact's Email Address *
example@example.com
Your Medical Information
List all medications you are taking *
List any doctors whose care you are under *
List any allergies *
List any medical problems *
Consent and Agreement
Insurance is not provided for accident, injury, or illness on the premises or during transportation to and from Abba House, Inc. for any reason. I understand that I am solely responsible for any medical bills I or any member of my family incur or damage I or any member of my family cause while at Abba House, Inc.. I hereby assume any risks that may be incident to my stay at Abba House, Inc. and agree that neither I nor any of my heirs or assigns will hold Abba House,Inc. Responsible for any damages that occur during my stay at Abba House and I hereby release and relinquish forever any and all claims of any nature whatsoever that might arise out of my stay at Abba House, Inc. , 2089 HWY 41 South, Perry GA 31069. I also understand Abba House, Inc. is a church and that ministry I receive is based on the staff’s understanding of Christian principles and the Holy Bible. *
Signature - By typing my name and submitting this form I agree to abide by the Abba House rules.
Please enter the message as it's shown and then click the Submit button below to finalize your application submission. *
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Your Personal Information Section