ALPHA & OMEGA MINISTRIES
RESIDENT INTAKE INFORMATION 1 OF 2 PAGES
OFFICE USE ONLY:_____
DATE REVIEWED:_____
DATE ACCEPTED/DENIED:_____
Date:_____________________
Name:_________________________ Social Security #__________________________
Previous Address:________________________________________________________
City/State:__________________________ Zip:_______________
Do you own a vehicle Y/N ______ If yes, Are you expecting to have it at A & O _______
D/L # ____________ Make of car:____________ Plate # ________________________
Are you: Married ( ), Single ( ), Divorced ( ), Separated ( ), Widowed ( ).
Date of Birth:_______________ Age:________________
Number of children:________________ Ages:_________________________________
What arrangements are being made for these children?__________________________
What (is/are) your source(s) of income? SDA ( ) ADC ( ) SSI ( ) Other_______________
Are you employed? Where? _______________________Phone # _________________
In case of emergency, who is to be contacted: Name: ___________________________
Address: __________________________
Relationship: ______________________
Phone # __________________________
Where can you be contacted regarding the council’s decision: Phone # _____________
Since we are Christian based Ministry and not a shelter, we do expect appropriate behavior while you
are a resident at Alpha & Omega Ministries.
THE FOLLOWING INFORMATION WILL BE HELD IN CONFIDENCE, IT WILL BE REVIEWED BY THE
A & O COUCIL SO THAT THEY CAN MAKE A DECISION ON YOUR REQUEST FOR RESIDENCE. TO
OMIT OR GIVE FALSE INFORMATION WILL BE GROUNDS FOR REFUSAL OF RESIDENCE OR IF
DESCOVERED AFTER YOU ARE APPROVED NAY CAUSE TERMINATION OF RESIDENCE.
1. Are you currently under the care of a physician for any of the following:
Emotional/mental stress ( ), Allergies ( ), Other ( ) Please explain:
______________________________________________________________________
___________________________________________________________________________________
_________________________________________________________
Medications taken: _______________________________________________________
Name of physician/counselor: ______________________________________________
2. Have you ever been institutionalized for mental or emotional problems ____________
Where and Why: ________________________________________________________
