Men’s Application

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 the info and willing to consider what Bethel has to offer
I Agree (required)

Have you ever been to Bethel Colony before? YesNo

Full Legal Name: (required)

Date of Birth: (required)

Age:

Social Security #(last 4 digits only): (required)

Phone: (required)

Alt Phone:

Current Mailing Address:

Mailing Address: (required)

City: (required)

State: (required)

Zip Code: (required)

E-mail: (required)

Did you graduate from high school?YesNo If no, GED? Yes

Give a name & number of a personal reference we may contact:

Contact:

Phone#:

A. Please explain briefly why you want to come to Bethel Colony of Mercy?

B. When did you have your last drink or drug?

What was it?

C. What drugs have you used?

Anything IV?YesNo
Alcohol?YesNo

Are you subject to DT's or seizures?YesNo

NOTE:(Must be detoxed at least 5-7 days) If you come in requiring detox, you will be asked to leave and return after detoxification and WILL be required to start Bethel's program over once you have completed detoxification.

D. What is your marital status?

E. Who are you living with now?

Relationship

Can you return there when you leave Bethel?YesNo

F. Do you have a job you can return to when you leave Bethel?YesNo

G. Would it be ok to do a criminal background check?YesNo

If no, please explain:

H. Have you ever been to jail or prison?YesNo

If yes, please explain:

I. Do you have any pending charges/court dates?YesNo

If yes, please explain:

J. Are you on parole or probation?YesNo

If yes, please explain:

To whom do you report?
NAME:
PHONE #:

K. Do you have a prior criminal record?YesNo

If yes, please explain:

L. Are you a felon?YesNo

M. Are any warrants pending?YesNo

If yes, please explain:

NOTE: If you are a felon you must send a copy of your Criminal Record. If you choose to stay in the Lenoir area when you leave Bethel, we may notify the local authorities. We require that all outstanding legal issues be addressed before entering our program or be postponed until you have completed the program.

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? YesNo

If yes, please explain:

4. Do you smoke? YesNo Do you use smokeless tobacco? YesNo

We discourage smoking but allow it in designated areas and at specified times only. Cigarettes only; - vapes, e-cigs, roll your own or any other form of tobacco are not allowed.

You are responsible for your own cigarettes and we will not take responsibility for providing those for you or replacing any that are misplaced.

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 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.

There is also a $10.00 drug-screening fee when you check in to Bethel. After that, any time you have a visit you will be required to pay a $10.00 fee before you leave on your visit to cover a drug screening upon your return.

5. HEALTH AND RELATED ISSUES.....

A. How would you rate your overall health?GoodFairPoor

Do you have any KNOWN ALLERGIES?YesNo
If yes, please list:

Must bring Epipen with you, if needed.Do you have any disabilities?YesNo
If yes, please explain fully:

List all of your limitations:

Treatments:

List any medications you are currently taking:

List any you are supposed to be taking but are not:

If you are on antibiotics, we must know why you are taking them:

We will also need a letter from your treating doctor confirming this.

PLEASE HAVE ALL PRESCRIPTION MEDICATIONS FILLED BEFORE COMING as well as ALL NEEDED REFILLS FOR THE 65 DAY PROGRAM.

B. What is the date of your last hospitalization?

Explain reason for hospitalization:

C. What is the date of your last physical examination?

Explain results?

D. Have you ever had Hepatitis?YesNo

If yes, which kind?

When?

Is it in remission?YesNo

Send a doctor's letter confirming your current status.
If Hep C - you will need a doctor's letter stating you will not need treatment while at Bethel.

E. Have you ever had TB?YesNo

If yes, when?

If yes, you will need a doctor's letter stating you have been cleared and no further signs are evident.

F. Have you ever tested positive for HIV?YesNo

If yes, when?

G. Have you ever been diagnosed with schizophrenia and/or personality disorder?YesNo

If so, what was the diagnosis?

H. Please check any of the following you have been diagnosed with:

DiabetesEmphysemaHeart ProblemsHigh Blood PressureHypoglycemia

ANY sexually transmitted diseases?YesNo

If yes to STD's, which one(s)?

I. 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, attn: Men's Campus,

Email to: bcoffice@bethelcolony.org

or Mail to:
Bethel Colony of Mercy
1675 Bethel Colony Rd.
Lenoir, NC 28645

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.

Absolutely no medications on the DEA's list of scheduled medications will be allowed, such as; xanax (alprazolam), klonopin (clonazepam), buprenorphine (suboxone, subutex), methadone etc. (THIS LIST IS NOT ALL INCLUSIVE)

J. 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).

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

7. You are required to have someone bring you to our facility. (You cannot drive yourself) Who will be transporting you to and from our location?

8. These are the items you will need:

- Bring work and dress clothes Some that are not allowed are: no words or photos with drugs, tobacco, alcohol, or anything contrary to a Christian lifestyle.

- Bring your own washcloths, towels, and 1 pillow. (mark your name on them). Bed linens are provided.

- Bring your own personal toiletry items (nothing with alcohol, ie; mouthwash, colognes, or aerosols)

- Bring a cloth mesh 36 x 24 laundry bag. A wrist watch (no smart watches are allowed) is recommended. (Both can be purchased at Wal-Mart.)

- Vitamins which are new with the seal unbroken.

- Napkins, toilet tissue, paper towels, facial tissues, laundry detergent(POD's are recommended).

- Bring a Bible if you have one.

These are the items that are NOT allowed:

- NO BODY PIERCING RINGS OR STUDS WORN ANYWHERE ON YOUR BODY!!

- Personal bed linens are NOT permitted.

- No audio or video apparatus: CDs, DVDs, MP3, IPods, Video Games, etc.

- No over the counter medications.

- No caffeinated drinks, coffee, or pills.

- NO cell phones, tablets, or smart devices.

9. We are offering to help you overcome your bondage, however, this must be on our terms.

Are you willing?YesNo Do you still want to come?YesNo

10. If you have any questions, please email Bethel at bcom@bethelcolony.org 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.Yes (required)

I HAVE READ THIS ENTIRE APPLICATION AND AGREE TO FOLLOW ALL THE GUIDELINES SET IN PLACE BY BETHEL COLONY OF MERCY. BY SIGNING, I PROCLAIM I HAVE ANSWERED HONESTLY TO THE BEST OF MY ABILITY. I UNDERSTAND ANY ANSWERS GIVEN WHICH ARE FOUND TO BE INACCURATE MAY BE REASON FOR ME TO BE ASED TO LEAVE THE FACILITY.

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

I have read and will comply with the above regulations.Yes (required)

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 $350.00 Entry Fee before you will be called to come to Bethel. Once entered into the program this Entry Fee is non-refundable.

There are now two ways to pay your Entry Fee:
1. Mail a 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.
2. Pay your Entry Fee online. There is an additional non-refundable fee for the online payment of your Entry Fee.

Victory Through Christ

Victory Through Christ

Men’s Application