Changed Lives Ministry Student Application
Please neatly print all requested information. Name____________________________________________ Date__________________
Name you like to be called ____________________________
Other Numbers where you could be reached__________________ __________________
____________________ _____________________ ____________________________
Date of Birth _______/______/_______ (month day year )
Age ______ Height______ Weight ________ Can you read well?_____.not well_______
Social Security Number _________/_________/___________
Valid Drivers License Number ________________________State_____________
If Married, Spouse’s Name__________________________________________________
Children? _____Names and Ages______________________________________________
Addiction and Medical Issues
List the substances to which you’re addicted:
List other medications you are currently taking:
List all medical conditions (bi-polar, handicapped, schizophrenia, etc.):
Have you ever had convulsions, seizures, or blackouts? Yes________ No_________
List any allergies___________________________________________________________
Do you have heart disease, diabetes, epilepsy, respiratory disease, etc.? Yes____No____
Do you have a Naltrexone Implant? Yes_____ No_____
Do you have a doctor? Name/Number____________________________________
Sign here to give permission to Changed Lives Ministry to consult with your doctor, insurance company, or health department about your medical situation:
List all pending court dates, jail terms, Charges, etc.:
Are you ordered by the court to enroll in this program? __________________
Are you under bond? ________________County/State___________________________
Do you have a Probation Officer? ____ Name/Number____________________________
Do you have an attorney? ______ Name/Number _______________________________
Sign here to authorize Changed Lives Ministry to a background check, consult with your Probation Officer and/or your attorney regarding your legal situations:
Sign your name__________________________________ Date___________________
Probation Officer Consulted? _____ Date: ________/__________/_________
Probation Officer’s Name/Number ___________________________________________
Attorney Consulted? ______ Date: __________/__________/_________
Attorney’s Name/Number __________________________________________________
Manager/Director Signature:_________________________________ Date ___________
What to bring with you to the Ministry . $300 Medical Deposit (Cash or Money Orders only: No personal checks) . Since living space is limited, do not bring more than 2 pieces of luggage, not including bedding or towels, etc. . Phone card, if you wish to make any calls (only after 2 weeks into the program) . Clothes:
Blue jeans, shorts & athletic shoes are acceptable, except for Sunday morning.
Provocative or tight fitting clothes are prohibited for students & their guests.
Cold weather items, in winter, (coats, hat, gloves, boots, etc.)
Work clothes & shoes, shirt, tie & pants for Sunday
Don’t bring too many clothes, because storage space is small, but bring enough to make it for a week between washings. . Pencil, pen, bible, writing paper. . Twin size bed linens: 2 fitted, 2 flat, 2 pillow cases, pillow, and blanket. . Four towels and wash cloths. . Personal hygiene items (soap, tissues, deodorant, etc.) (no alcohol containing products). . A good attitude. . A willingness to work, whatever jobs are assigned to you. What not to bring with you . Vehicles . Alcohol-based products of any kind . Body sprays (‘AXE’ , ‘Tags’ , etc.) . Personal electronic devices, including cell phones. . Pornography . Weapons, drugs, alcohol and other obviously prohibited items or substances Pre-Admission Blood Test Report
This form is to be submitted to your health care provider (doctor, clinic or Health Department), then faxed directly to Changed Lives Ministry by your provider.
__________________________ has applied for entrance into Changed Lives Ministry for a ten week drug and alcohol rehabilitation program.
Blood Tests for the following are required for admissions into our program:
HEPATITIS C _______________________________________________________
Please complete in full, then fax directly, with your agency’s cover sheet, to Changed Lives Ministry @ (843)-899-4014. CHANGED LIVES MINISTRY
Monck’s Corner S.C. 29461 (843)899-4014
Thank you for your interest in the Changed Lives Ministry drug and alcohol addiction recovery program. Based on the information you have already shared over the phone, you appear to be a potential candidate. We’ve enclosed an application for you to complete and forward back to us. We are praying for you, that God will continue to work in your heart and assure you of His love and good purpose for you. God through Jesus Christ, is able not only to rescue you from your addiction, but to give you a brand new life! Our prayer is that you will come to our program and later leave a new or renewed man in Christ!
Be careful to provide all the requested information. Any information you provide which proves to be incomplete or inaccurate will invalidate you application. After receiving and reviewing your application, we will send further instructions.
We believe the Bible to be God’s inspired, inerrant, and eternal Word. We believe sin is the problem beneath and behind all addictive behavior. We believe Jesus is the Son of God, sent into the world to save sinners.
Our program will help you focus on Jesus Christ, as the Bible describes and explains Him. We study, pray and interact with each other, focusing not so much on past life experiences and failures, but on what God promises to do with a life surrendered to Him.
The program includes housing, meals, and a structured daily routine designed to nourish and develop you mind and body, as well as your soul.
We look forward to hearing from you. What to Expect at Changed Lives Ministry
God brought you to our Ministry to save your life from alcohol and /or drugs, through a personal relationship with Jesus Christ. You are not here by chance, but by God’s plan. Jesus says,“Come to Me, all you who are weary and burdened, and I will give you rest.” (Matt.11:28)
Throughout your program, you will be pointed to Jesus Christ, as the Bible describes and presents Him. He alone can give you the victory over substance abuse. Jesus says,“If therefore the Son shall make you free, you shall be free indeed.” (John 8:36)
You will spend much time studying the Bible and hearing it preached and taught. “Then you will know the truth, and the truth will set you free. (John 8:32)
You will spend time in worship, focusing on Jesus Christ and how wonderful and powerful is the love of God which sent Jesus to die for our sins. “How great is the love the Father has lavished on us, that we should be called children of God!. (1 John 3:1)
You will be surrounded by the love and compassion of Jesus Christ in this place, and will be encouraged to share that love with others. “And this is His commandment, that we believe in the name of His Son Jesus Christ, and love one another, just as He commanded us.” (1 John 3:23)
You will have the opportunity to learn to pray, to share your burdens with Jesus Christ, and to experience the peace and comfort of His care for you. “Cast all your anxieties on Him, for He cares about you.” (1 Peter 5:7)
You will learn of your need to trust and depend on Jesus Christ, not only for victory over abusive substances, but for literally everything in your life. Jesus says, “Abide in Me, and I in you, As the branch cannot bear fruit of itself, unless it abides in the vine, so neither can you, unless you abide in Me.” (John 15:4)
Welcome to Changed Lives Ministry! Enrollment Contract . I am coming on my own free will, not because someone else is forcing me to come. . I understand that Changed Lives Ministry is not responsible for any of my medical care costs; therefore, I am submitting a $300 medical deposit. If I am injured or in pain, and if the Staff determines that my situation does not require visit to the doctor or emergency room, I will be given the option of pleasantly tolerating my pain, or leaving the program to have my medical needs addressed, with the option of later reapplying for entrance into the program. I release Changed Lives Ministry from any legal claims associated with these issues or regarding my stay here. . I promise to complete the ten-week program . I promise to work hard, whatever jobs are assigned to me. . I promise to read and obey all rules and instructions with a good attitude. . I promise to show respect for anyone in authority over me, including completing any disciplinary work that may be assigned to me. . I promise to show respect and consideration for other students and visitors. . I expect to have my things, my room, my person, and my visitors searched and /or tested for drugs and alcohol at any time during my stay, and at any time I may later visit. . I realize that I will be immediately dismissed from the program if my girlfriend visits me before graduation weekend, or if my visitors are using or bring any forbidden substances onto this property. . I understand that the Staff may dismiss me from the program at any time for any actions or attitudes on my part they judge as sufficient cause, including, but not limited to: laziness, racism, gossip, vulgarity, womanizing, threats, practical jokes, smoking or chewing tobacco or dipping snuff inside any building, misusing the phone, possessing a cell phone, driving without a license, etc. . I authorize Changed Lives Ministry to share any information or records about me, as deemed appropriate by the admisistration.
I understand and completely accept these conditions of enrollment at Changed Lives Ministry Program.
Student Name (Printed)_________________________________
CHANGED LIVES MINISTRY Rules of Conduct and Behavior
If, at any time, a Staff or Senior Student observes me to be out of compliance with any of these rules, and calls it to my attention, I will respond respectfully and be expected not to repeat the same unacceptable behavior again, or else be subject to a disciplinary meeting with the director. If Staff assigns me any disciplinary homework, I will respond respectfully and do all that is required of me within the assigned time limits.
1. A good and respectful attitude is required of me, whatever jobs assigned, or
whatever requests are made of me by any Staff or Senior Student.
2. I am to observe quiet reverence in preparation of all worship services. 3. I may use the restroom during free times only. If I need to use the restroom
during worship services or classes, I must politely request and obtain permission from a Staff or Senior Student.
4. I am responsible to work with my roommates to keep our room clean and neat,
including dusting, vacuuming, sinks, mirrors, showers, toilets, making our beds, etc. I expect daily room inspections.
5. I am not permitted to smoke, chew tobacco or dip snuff, except outdoors in
6. I may send and receive mail during my entire stay at the Ministry. 7. I may make 15 minute phone calls on the weekends after 2 weeks into the
program. Phones will be available only on the weekends. Calls will be made from noon until 8:00 on Saturdays and Sundays.
8. Only immediate family members or church members may visit me except by
permission of the Manager or Director.
9. After 5 weeks, visitors may visit me on Saturdays from noon until 6:00 PM and
Sundays from 1:00 PM until 5:00 PM. Visits during any other time must be approved in advance by the Staff.
10. Family members may attend morning and evening worships services on Sundays. 11. My girlfriend may not visit except for graduation, If she shows up, or if my
visitors are using or bring any forbidden substances onto this property, I will be immediately dismissed from the program.
12. I may not leave the property with my visitors, except on graduation weekend, by
prior approval by the Manager or Director.
13. I am to instruct my visitors to sign in and out at the office. 14. My visitors must call by Wednesday afternoon before they come for a visit. 15. My visitors may not wear provocative or tight fitting clothes. 16. I may not spend the night with my wife, except after graduation
17. I understand that I am not to fraternize with females during my residency. This
includes engaging in conversations or sitting with in worship services/Sunday school (except for immediate family members.)
18. I am required to be at all meals, services and meetings on time. If I am sick in the
morning, I am required to come to breakfast and the Staff member in charge will determine if I am sick enough to go back to bed, If I am sent back to bed, I must remain there until the next day, except for meals. During a sick day, I may not smoke, chew or dip except at meals, and then only on the outside.
19. I am to memorize my daily memory verse for each breakfast session. If I am
Having trouble memorizing, I will ask for help in preparation. If Staff or a Senior Student determines that I am weak in this area, they may assign copying homework to help me incorporate Bible verses into my memory.
20. I will complete the Bible Study Workbook sections in my notebook, and
submit them to the Manager after the 9th week for his review.
21. I am required to wear clean and neat (not torn or ragged) collared shirts and long
pants to Sunday morning worship services and to keep myself clean and neat at all times.
22. I expect to have my things, my room, my person, my mail and my visitors
searched and/or tested for drugs and alcohol at any time during my stay and at any time I might later visit the Ministry.
23. I am required to report to the Manager the presence of any alcohol, drugs or
pornography on the property or I will be in trouble myself.
23. I am not permitted to possess any electronic devices, nor am I allowed to operate any audio-visual equipment. (which includes changing channels on TV) 24. I am to bring all books and magazines, other than Christian Bibles, to the
25. I am to remain on property at all times, except by permission from Staff. 26. I am not allowed to make any room modifications (painting, furniture, etc.) without prior Staff approval. 27. All my medicines will be held in the office and dispensed daily. 28. I am not allowed in the Staff office or Kitchen without Staff permission. 29. I am not allowed in any Staff rooms at any time. 30. I am not allowed to lie down or sleep in any bunk except my own, and at approved times
31. Changed Lives Ministry is not responsible for any of my medical care costs. My
medical deposit will be used to obtain medicine or medical care, pay for medical trips to town, etc.
It’s a privilege, not a right, to be here
I understand that the Staff may dismiss me from the program at any time for any actions or attitudes on my part that he judges as sufficient cause, including but not limited to laziness, racism, gossip, vulgarity, womanizing, threats, practical jokes, smoking or chewing tobacco or dipping snuff inside any building, misusing the phone, possessing a cell phone, driving without a license, etc. MEDICAL POLICY AND MEDICATION LIST
Changed Lives Ministry does not provide on on-site doctor, nurse or clinic. Medical emergencies are handled through the local hospitals. ( A $300 medical deposit is due upon arrival for entrance into the program.)The Ministry prohibits the following substances:
Sedatives that might impair a student’s ability to: < Engage himself fully in the program< Engage himself safely in the work program
Anything containing alcohol, including mouthwash, hairspray, cough syrup, etc.
Mood altering medications, except as listed below
Body or muscle-building ingredients or mixtures, or high-energy drinks or mixes
Special Rx needs for Asthma, diabetes, blood pressure, etc. will be individually addressed.
The following medications will be allowed:
Ibuprofen, Aleve, Aspirin, Tylenol, Advil, etc.
Paroxetine (Paxil, Aropax, Deroxat, Paroxat, Seroxzt, Tagonis
All allowed medications are to be dispensed by Office Staff, dose by dose. No medications are allowed in student’s room or possession.
Changed Lives Ministry Mission Statement
Changed Lives Ministry is a Christian Rehabilitation Center dedicated to men addicted to drugs, alcohol or any other addiction and are committed to re-establishing themselves in the community. The ministry provides a structured Christian lifestyle and a safe environment for trouble individuals to overcome whatever problems they may be facing.
Changed Lives Ministry is a 10-week program and is based on the belief that faith in God, strong work ethics, and the basic practice of self-discipline will enable any individual to attain victory over their problems. We firmly believe that God leads these men to this facility, both to plant the seed of Christian truth and cultivate moral responsibility. The guest come here for positive change and get out of the program what they put into it.
Our intention is not to have a prison-like atmosphere, but to grow in love through a personal relationship with our Lord Jesus Christ. Basic rules have been implemented and are necessary to maintain structure and accountability, which is Biblically grounded. Management handles rule violations on a case-by-case merit. Every resident is closely monitored by our staff, whom resides on site. Their progress is documented in their personal files and discussed in weekly board meetings.
Candidates for our program go through a screening process which includes telephone conversations, application submittal, health screening, back-ground checks and interviews with family members to establish their commitment to change their lives. The program includes housing, meals, and a structured daily routine designed to nourish and develop the mind and body, as well as the soul.
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