Application

If you are interested in entering Bethel for help with your addiction(s), first review the
"About Us, Schedule and Testimonies" sections on this website. THEN complete
(printing legibly in English) the following application form and call 828-754-3781 for a
registration number and the number to FAX this application.
ONLY THE PERSON APPLYING MAY CALL TO REGISTER!
Applications without a registration number will not be considered.

Registration #__________________________

Teenagers must be approved by one of our staff ministers.
Approved by _____________________________________(Office use only)

RESIDENT APPLICATION to BETHEL COLONY of MERCY

1. Bethel Colony of Mercy is a faith ministry which depends solely on donations.

2. Bethel Colony of Mercy is a Christian renewal center designed to help men who are truly
ready to make a change in their life. Victory in living through Jesus Christ and the truth of the Bible
is taught here. This is accomplished through classroom teaching, audio & video tapes, one-on-one
counseling, homework assignments, worship services and work projects.
I have reviewed this info and am willing to consider what Bethel has to offer. ____Yes ____ No

We will accept your application; however, you will be on probation and if you are not showing serious
intent of changing your life while at Bethel you will be asked to leave to make room for those who are serious.

Have you ever been to Bethel Colony before? ____ Yes ____ No

        Your Name: ______________________________________ Age ______
        Date of Birth _____________     Social Security # ( last 4 digits only ) ________
        Phone # (A)____________________ (B)_______________________
        E-mail______________________________
        Address ______________________________________________________
                     ______________________________________________________
                     ______________________________________________________
        Did you graduate from high school? ___Yes ___ No (if no) GED? ___Yes ___ No
        Please give the name of a personal reference we may contact:
        ___________________________________________________________________
        Address ______________________________________
                      ______________________________________
        Phone # ______________________________________

        A. Why do you want to come to Bethel Colony of Mercy? ____________________________
               _______________________________________________________________________
               _______________________________________________________________________

B. When did you have your last drink or drug? ___________________
What was it?___________________________________________________________

C. Are you subject to DT's or seizures? ____ Yes ____ No
(You must be drug free or detoxed at least 48 hours before arriving at Bethel Colony.)

D. What is your marital status? ____Single ____Engaged (with a ring)
____ Married ____Separated ____Divorced ____Widowed

       E.    Who are you living with now? __________________________________
               Relationship ____________
               Can you return there when you leave Bethel? ____ Yes ____ No

F. Do you have a job you can return to when you leave Bethel? ____ Yes ____ No

G. Would it be ok to do a criminal background check? ____ Yes ____ No
If no, explain____________________________________________________________

H. Have you ever been to jail or prison? ____ Yes ____ No
If yes, explain___________________________________________________________

       I.    Do you have any pending court dates? ____ Yes ____ No
              If yes, please explain fully: __________________________________________________
              ______________________________________________________________________

       J.    Are you on parole or probation for anything? ____ Yes ____ No
              If yes, please explain fully: ___________________________________________________
               _______________________________________________________________________

      K.    Do you have a prior criminal record? ____ Yes ____ No
              If yes, please explain fully: ______________________________________________________
               _________________________________________________________________________

L. Are you a felon? ____ Yes ____ No

      NOTE: If you are a felon you must send a copy of your Criminal Record.
      If you choose to relocate in the Lenoir area when you leave Bethel,
      we may notify the local authorities.

3.    The program at Bethel is for 65 consecutive days and we expect you to make a firm
       commitment to fulfill all 65 days. Is there anything, including finances, that would
       prevent you from doing this? _____ Yes ____ No
       If yes, please explain fully: _______________________________________________
      ___________________________________________________________________
      ___________________________________________________________________

4.    Do you smoke? ____ Yes ____ No Do you use smokeless tobacco? ___ Yes ____ No
       We discourage smoking but allow it in designated areas only. Cigarettes only, we do not allow
       any other form of tobacco.

       We have other rules we expect you to comply with such as limited TV choices and not leaving
       the grounds without permission, which is a check out offence. You are required to participate
       in the daily work projects. Work projects are designed to produce discipline and responsibility. We
       are not a source of income. We are a faith ministry and there is no charge to stay here. There is a
       $65 non-refundable entry fee and we ask that you send it in before entering the program. We also
       ask that you bring toilet paper, paper towels, and laundry detergent when you check-in to Bethel,
        if possible.

5.    HEALTH AND RELATED ISSUES......
       A.    How would you rate your overall health? ____ Good ____ Fair ____ Poor
               Do you have any disabilities? ____ Yes ____ No
               If yes, please explain fully: ______________________________________________
               __________________________________________________________________
              Treatment: __________________________________________________________
              Medications: _________________________________________________________
              Limitations: __________________________________________________________

All students with disabilities must submit a current medical record from their medical
doctor stating limitations of their disability prior to admission.

B. When were you last in the Hospital? ______________________________________
For what? _________________________________________________________

C. What is the date of your last physical examination? ___________________________
What was the result?__________________________________________________

       D.   Have you ever had Hepatitis? ____ Yes ____ No   If yes; which kind? ___________
               When? _____________________ Is it in remission? ____ Yes ____ No
               Send a doctor's letter confirming your current status.

E. Have you ever had TB? ____ Yes ____ No If yes, when? _________________
Treatment: _______________________________________________________

        F. Have you ever been told you have any of the following? ____Diabetes ____Emphysema
              ____ Heart Problems ____Ulcers ____High blood pressure ____ ANY sexually
             transmitted disease? If yes to STD's, which one(s)? ___________________________
             ___________________________________________________________________

        G.    You must have a TB and HIV test done prior to being admitted to Bethel . (Flu Shot from
                October through March with documentation.) These test results may take up to a couple of
                weeks. You will not be placed on the active waiting list until we receive at least one of the
                test results. Fax results to: Office Manager, (828) 754-5370
                or mail to: Bethel Colony of Mercy, 1675 Bethel Colony Rd., Lenoir, NC 28645

        H.   Are you currently on any medication or supposed to be taking any medication?
               ____ Yes ____ No   If yes, which medication(s)? _______________________________
               ___________________________________________________________________
              (a) If you are on antibiotics, we must know why you are taking them: _________________
               ___________________________________________________________________
               We will also need Medical Records from your treating Doctor or Dentist.

PLEASE HAVE ALL PRESCRIPTION MEDICATIONS FILLED BEFORE COMING

The following is a list of medications NOT ALLOWED while at Bethel. They are listed with brand name and
generic name following in parentheses:   valium (diazepam), xanax (alprazolam), serax (oxazepam),
ativan (lorazepam), halcion (triazalam), dalmane (flurazepam), restoril (temazepam), klonopin (clonazepam),
tranxene (clorazepate), librium (chlordiazepoxide), sonota and ambien.

        I.    What drugs have you used? ____________________________________________
               _________________________________________________________________
               _________________________________________________________________
               IV drugs? _________________________________________________________

J. (a) If you have any open wounds of infections, they must be treated and healed before
you enter Bethel Colony. This includes injection sites for IV drug users.

              (b) You must be free from all infectious diseases, such as Staph, MRSA, and Strep.
               (Herpes must be dormant)

       K. Is there anything else you can think of that would help us to minister to you? _________
             ____________________________________________________________________

6. How will you arrive at Bethel? (You cannot drive yourself)___________________________

**Please read the following notes of interest before faxing your completed application.**

7.    (a) Bring work clothes and dress clothes. (NO SLOGANS ABOUT BEER, BARS, DRUGS, SEX
       WOMEN, TOBACCO, MUSIC, OR ANYTHING ELSE CONTRARY TO CHRISTIAN
        LIFESTYLE)
        (b) Bring your own wash clothes, towels, and personal toiletries (NOTHING WITH
        ALCOHOL, NO MOUTHWASH, NO COLOGNES, AND NO AEROSOLS)
        (c) NO BODY PIERCING RINGS OR STUDS WORN ANYWHERE ON YOUR BODY
        (d) No radios, walkmans, CD/Tape/MP3/DVD's of any kind. NO cell phones. No video games or
        or cards.
        (e) No over the counter medication. No caffeinated drinks or coffee. You may bring vitamins
        but they must be new and in their sealed container.
        (f) Bring Bible if you have one.
        (g) If possible bring toilet paper, paper towels, and laundry detergent.

8. We are offering to help you overcome your bondage, however, this must be on our terms.
Are you willing? ____ Yes ____ No Do you still want to come? ____ Yes ____ No

I have answered all of the above questions on this application honestly and to the best of my
ability.

Signed: _________________________________ Date:__________________________

I have read and will comply with the above regulations.

Signed: __________________________________ Date: ________________________

PLEASE REMEMBER TO CALL (828)754-3781 FOR A REGISTRATION NUMBER!

If you have any questions, please email Bethel at bethelcolony@charter.net and we will respond
quickly.