New Life Application

General Information

As you complete the application below, please click inside the text boxes to see all possible responses.

Name(Required)

First Last

Date of Birth(Required)

Sex (as identified by your government-issued ID)(Required)

Who is completing this form(Required)

If so, your relation to the applicant(Required)

Contact Information

Email Address (primary contact)(Required)

Phone Number(Required)

Current Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Best Way to Contact You(Required)

Secondary Contact

Name(Required)

First Last

Email(Required)

Phone(Required)

Past Knox Area Rescue Ministries Experience (KARM)

Have you ever stayed at KARM before?(Required)

How did you hear about the program?(Required)

Reason for wanting to enroll into KARM’s New Life Program(Required)

Are you currently or soon to be experiencing homelessness?(Required)

Safety

Are you fleeing from someone?(Required)

Are you in immediate danger?(Required)

Family History

What is your marital status?(Required)

Are you required to pay child support?(Required)

Are your payments current?(Required)

Income Status

Are you currently receiving any form of income?(Required)

What is the source of your income?(Required)

What is the total monthly amount of your income?(Required)

Are you currently employed?(Required)

KARM’s Berea program is a long-term residential program. Although we eagerly await assisting our residents with employment, residents won’t be able to work or attend school during the first 12 months of the program. However, there are opportunities to obtain a GED if that is a need.

Are you currently in school or in a training program?(Required)

KARM’s Berea program is a long-term residential program. Although we eagerly await assisting our residents with employment, residents won’t be able to work or attend school during the first 12 months of the program. However, there are opportunities to obtain a GED if that is a need.

Are you a veteran?(Required)

Health

Have you been prescribed any medications for a physical and/or mental health diagnosis?(Required)

What are the medications?(Required)

Do you have a mental health diagnosis?(Required)

What is/are the diagnose(s)(Required)

Legal

Answering ‘Yes’ to any of the questions below will not disqualify you from being considered for KARM’s Berea program.

Have you ever been arrested?(Required)

Have you been charged with any violent crimes?(Required)

Have you been convicted of a crime involving children or the elderly?(Required)

Are you a sex offender?(Required)

Do you have any pending charges?(Required)

Final Questions

How can we pray for you?(Required)

New Life is not a medical or psychiatric facility. If needed, we'll assist you in finding suitable detox options before joining New Life. To help us make informed decisions and ensure the best fit, we may request medical or mental health information. If later it's found that our program isn't the right match due to undisclosed medical or psychological concerns, we may recommend alternative options or collaborate with referring agencies. Please know your well-being is our top priority.(Required)

I understand and agree to the above statement

Type your name below. This will serve as your electronic signature.(Required)

Date Admission Agreement was Signed(Required)