APPLICATION

Dear Prospective Redeemed Lives Program - New England Participant,

The Redeemed Lives Program - New England program will begin on 10/4/2010 and end on 5/3/2011.
The meetings will be held at the following location:

Location:	TBA
Address:	TBA

To explore possible participation in Redeemed Lives Program - New England , you must:

1. Fill out this application, sign the release form and either hit the submit button or
mail to the address below:

	info@redeemedlives.org
	PO Box 451
	Ipswich, MA 01938

2. After your application is received, you will be contacted by telephone/e-mail
    and be interviewed at an assigned date and time.

   The interview will be conducted by a small group leader of your same gender. If
   you have been accepted into Redeemed Lives Program - New England we will notify you by phone/e-mail. However, if we
ascertain that Redeemed Lives Program - New England is not the right fit for your needs, then we will inform you.

Applications will be handled with respect for personal privacy. Only the speaker,
your interviewers, and your future small group leader(s) will read them.
The person telephoning you to schedule your interview will not read your
application.

This is a big commitment. Please prayerfully count the cost of your time and
energy. May the merciful hand of God be with you as you seek the Lord about
being part of Redeemed Lives Program - New England .

In Christ,
Redeemed Lives Inc.

Cost: $350.00


Program fee may be paid in installments, if necessary. The book fees and your initial program
deposit must be paid at the first meeting. Scholarships are available; these scholarships will be based
on need. Inability to pay for the program will not influence acceptance.

Redeemed Lives Program - New England

Application and Release Form

This application will be held strictly confidential. Only your interviewers and future small group leaders will read beyond page one.
Please answer questions in full.

	Personal Information
*	Required fields
*	First Name:
	Middle Initial:
*	Last Name:
*	Address1:
	Address2:
*	City:
*	State:
*	Zip:
	Day Phone:	- -
	Evening Phone:	- -
	Cell Phone:	- -
	Fax:	- -
*	Email:
	Gender:	Male Female
	Marital Status::	Single Married Divorced
	Age:
	Number of Children:
	College Student:	Yes No
	Name of College:

	Have you attended Redeemed Lives before? Yes No

	If yes: What year did you attend Redeemed Lives?
	Who were your small group leaders?

	If no: Then check all appropriate boxes below indicating where we may leave a message with your assigned interview day and time.
	Day Phone Evening Phone Cell Phone Fax E-mail

	Christian Background Information
	Are you a Christian? Yes No If yes, for how long?
	What is your church affiliation?
	If no church affiliation, are you willing to become part of a Christian fellowship? Yes No
	Please list any non-Christian religious and spiritual involvement, including activity in the occult.

	How do you feel about receiving healing prayer administered through the laying of hands, use of holy oil and water,
	and use of the gifts of the Holy Spirit?


	The Presenting Situation, Needs and Issues
	Please check all boxes that apply:
	Sexual Redemption Divorce Recovery Eating Disorder Other
	*What are your reasons for seeking help through Redeeemed Lives?*

	If not married, are you currently in a relationship which involves sexual contact? Yes No
	If not married, do you live with someone with whom you have been sexually active?Yes No
	Are you dating someone with whom you have been sexually active? Yes No
	Have you been tested for HIV? Yes No
	Do you live with someone with whom you have been emotionally dependent? Yes No
	Do you take any over-the-counter medications or illegal drugs?Yes No
	If yes, please list the medication(s) or drug(s)


	History of Seeking Help
	Have you sought specific help before? Yes No
	If yes, please describe.
	Have you been under the care of a psychologist or psychiatrist? Yes No
	If yes , were you given a DSM III-R or a DSM IV diagnosis? Yes No
	If yes, what was it? (use code number if you do not know the name.)
	Were you prescribed medication(s) for your need? Yes No
	If yes, please list all medications prescribed .

	Information about the Future
	Are you willing to take an HIV test if asked to? Yes No
	Are you willing to seek professional therapy if suggested? Yes No
	Are you willing to abstain from alcohol until Redeemed Lives Program - New England is completed, This may be a requirement for acceptance? Yes No
	Are you willing to break off all sexual contacts apart from marital relations? Yes No
	Are you willing to abstain from all drugs unless prescribed by a doctor? Yes No
	Can you make all of the meetings? Yes No
	*What are your expectations of Redeemed Lives?*



	Agreement and Release from Liability Form
	I, , acknowledge that I have (Please print first name, middle name, last name) voluntarily applied to Redeemed Lives Inc. to participate in Redeemed Lives Program - New England , a Christian, non-therapist, worship, teaching, discipleship and pastoral care group. I am aware that my participation is not a substitute for psychiatric treatment, medical treatment, psychotherapy, therapeutic counseling or any other form of professional therapy. I am also aware that my participation in is not a substitute for my active involvement in a local Christian church body of my choice. I am voluntarily participating in Redeemed Lives Program - New England with full knowledge of these facts and I accept complete responsibility for my own medical, psychiatric, psychological, mental, emotional and spiritual well-being. I acknowledge that it is my responsibility to ascertain my own need for professional counseling and to seek such professional counseling, as needed. I further acknowledge that my participation in Redeemed Lives Program - New England does not create any special relationship of custody or control between myself and Redeemed Lives Inc. (including any agent, employee, officer or director of Redeemed Lives Inc.) or between myself and any other person. As consideration for being accepted by Redeemed Lives Inc. to voluntarily participate in Redeemed Lives Program - New England , I, on behalf of myself and my assigns, heirs, executors, guardians and other legal representatives, hereby release Redeemed Lives Inc. (including all agents, employees, officers and directors of Redeemed Lives Inc.) from any liability for any injuries suffered by me during my voluntary participation in Redeemed Lives Program - New England , resulting from the negligent acts or omissions of Redeemed Lives Inc., or any agent, employee, officer or director of Redeemed Lives Inc., or resulting from the negligent acts or omission of any other participant of Redeemed Lives Program - New England . Further, I, on behalf of myself and my assigns, heirs, executors, guardians and other legal representatives, hereby agree that I will not make any claim against, sue or seek to attach the property of Redeemed Lives Inc. (including any agent, employee, officer and director of Redeemed Lives Inc.) and that I waive all actions, claims or demands that I now or hereafter may have, for any injuries suffered by me during my voluntary participation in Redeemed Lives Program - New England , resulting from the negligent act or omissions of Redeemed Lives Inc., or any agent, employee, officer and director of Redeemed Lives Inc., or resulting from the negligent act or omissions of any other participant of Redeemed Lives Program - New England . I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND REDEEMED LIVES INC. AND I HAVE CHECKED THE APPROPRIATE BOX BELOW INDICATING THAT THIS AGREEMENT IS ENTERED INTO OF MY OWN FREE WILL AND THAT I AGREE TO BE BOUND BY SAME AS IF I HAD SIGNED MY NAME AT THE END HEREOF Please check here if you are submitting electronically. I agree to the statement above. or Please print and sign here if submitting by mail:. Signature:____________________________ Date: _______________ Return completed Application and Release From Liability

When finished please click the Submit button.

When finished please click the Submit button.