Jumpstart Ministries
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OUR PROGRAM
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Jumpstart Ministries
Home
About Us
OUR PROGRAM
Application
The Team
Contact Us
Gallery
Home
Application
Application
JSM Application for Admission
Date
Full Name
Age
Date of Birth
Phone Number
Email Field
Maritial Status
Married
Single
Divorced
Separated
Do you have any child support or DHS cases opened at this time?
Yes
No
Are you willing to seek Jesus Christ as the answer to all your problems?
Yes
No
Do you have criminal cases pending?
Yes
No
If so what city county and state?
List probation or parole officer name and number.
List bondsman name and number.
If you have an attorney list their name and contact information?
Please list all charges
Have you ever been convicted of a sex crime?
Yes
No
List all your current medications and the dosages
Have you tested positive for sexually transmitted diseases such as HIV Hepatitis? (We do not disciminate.)
Yes
No
Do you receive any monthly benefits such as - pensions retirement SSI or disability?
Yes
No
If so how much to you receive?
Please provide emergency contact information. Include name relationship phone number and address.
Text Area
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