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 (in English) the following application form and we will contact you within 48 hours after we receive your application to continue the application process. (We MUST speak with the applicant when we call.)
Teenagers must be approved by one of our staff ministers. RESIDENT APPLICATION to BETHEL COLONY of MERCY
1. Bethel Colony 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 Click here Have you ever been to Bethel Colony before? yes no Click here
Your Name: Age Date of Birth Social Security # ( last 4 digits only ) Phone # (1st) (2nd) Address CityStateZip E-mail address
Did you graduate from high school? yes no Click here GED? yes no Click here Please give the name of a personal reference we may contact:
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 Click here (You must be 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 Choose one
E. Who are you living with now? Relationship Can you return there when you leave Bethel? yes no Click here
F. Do you have a job you can return to when you leave Bethel? yes no Click here
G. Would it be ok to do a criminal background check? yes no Click here If no, please explain:
H. Have you ever been to jail or prison? yes no Click here If yes, please explain:
I. Do you have any pending court dates? yes no Click here If yes, please explain fully:
J. Are you on parole or probation for anything? yes no Click here If yes, please explain fully:
K. Do you have a prior criminal record? yes no Click here If yes, please explain fully:
L. Are you a felon? yes no Click here 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 Click here If yes, please explain fully:
4. Do you smoke? yes no Click here Do you use smokeless tobacco? yes no Click here We discourage smoking but allow it in designated areas only. Cigarettes only, we do not allow any other forms 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 Click here If yes, please explain fully: Treatment: Medications:
All students with disabilities must submit a current medical record from their medical doctor stating limitations of their disability prior to admission.
B. What is the date of your last hospitalization? For what?
C. What is the date of your last physical examination? What was the result?
D. Have you ever had Hepatitis? yes no Click here If yes; which kind? When? Is it in remission? yes no Click here Send a doctor's letter confirming your current status.
E. Have you ever had TB? yes no Click here 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 called to come in Bethel. (Flu Shot required from October through March, you will need to have a flu shot 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 Click here If yes, which medication(s)? If you are on antibiotics, we must know why you are taking them: We will also need a letter from your treating doctor or dentist confirming this. 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. List all drugs you have used: IV drugs? yes no Click here
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)
7. (a) Bring work and dress clothes. NO SLOGANS ABOUT BEER, BARS, DRUGS, SEX, WOMEN, TOBACCO, MUSIC or ANYTHING CONTRARY TO THE CHRISTIAN LIFESTYLE will be allowed. (b) Bring your own washcloths and towels (mark your name on them) (c) Bring your own personal toiletry items (nothing with alcohol, ie; mouthwash, colognes or aerosols) (d) NO BODY PIERCING RINGS OR STUDS WORN ANYWHERE ON YOUR BODY! (e) No radios, stereos, walkmans, CD/Tape/MP3/DVD of any kind. No video games or cards. No cell phones or lap-top computers. In other words; no electronic devices period. (f) No over the counter medications. (g) No caffeinated drinks or coffee. Bring a Bible if you have one.
8. We are offering to help you overcome your bondage, however, this must be on our terms. Are you willing? yes no Click here Do you still want to come? yes no Click here 9. If you have any questions, please email Bethel at bethelcolony@charter.net and we will respond quickly.
10. Please keep in contact with us by phone or e-mail (bcoffice@charter.net).
I have answered all of the above questions on this application honestly and to the best of my ability.
Signed: Date:
**Please read the following notes of interest before submitting your completed application.**
I have read and will comply with the above regulations.
Please remember we will contact you within 48 hours after we receive your application to continue the application process, WE MUST SPEAK WITH THE APPLICANT AT THAT TIME! Please make sure we have a correct phone number to contact applicant.
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