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 72 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 $200 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. 

You need to take care of any dental, vision or any other medical issues before entering this
program.  We are not a medical facility nor do we have available the transportation to take
care of non-emergency medical needs.

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.   Please keep in contact with us throughout the application process.

        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.

Signed:  Date:

IF YOU HAVE ANY QUESTIONS REGARDING THIS APPLICATION PLEASE CALL
OUR OFFICE AT 828-754-3781.  Within 72 hours of receiving your application someone
from our office will call you to complete your application process.  WHEN WE CALL
WE MUST SPEAK TO THE PERSON APPLYING.  In the case that we have not talked to
you within the 72 hours please contact our office to complete your application process.

Please make sure that you have filled in the contact phone numbers where
you can be reached.

**REMEMBER**

After completing and submitting your application we will need the results of two blood tests (HIV and TB) and the $200.00 Entry Fee before you will be called to come to Bethel.

There are now two ways to pay your Entry Fee: 1. Mail a $200.00 money order to Bethel Colony of Mercy, 1675 Bethel Colony Rd., Lenoir, NC 28645. If you are paying by money order please make sure you write the applicant's name on the "For" line. or 2. Pay your Entry Fee online. There is an additional $7.00 non-refundable fee for the online payment of your Entry Fee.

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