Elijah Program Application

The Elijah Program

Specializing in Behavioral Modification Serving Children and Adolescents

Home of The Certified Christian Mentor and The Certified Mentor

Parents are too timid and children are too bold

F Nm.______________________MI____

Address: ______________________________________County: ________________________

City: ______________________________________ State: ___________ Zip:___________

D.O.B.: ____________________ S.S.# ______________________________ Grade:_______

Sex: _____ Home Phone #: ___________________________Years schooling:___________

Father s Name: ___________________________________Occupation:__________________

Work Phone #: _________________________________________________________________

Mother s Name: ___________________________________Occupation: _________________

Church Name:_________________________Denomination _____________________________

Address: __________________________City: ____________ State:____Zip:___________

Telephone: ________________Pastor: ____________________________________________

Have you ever been suspended from any school, yes___, no___ ?

Have you ever been arrested or held for questioning, yes___, no___?

If you have answered "yes" to either of the above two questions please explain on a separate sheet of paper.

I have read the Elijah Program philosophy. I understand that the program requires active participation by me and each member of my family. I further understand that there may be prescriptives assigned to me and/or other members of my family and I agree to accept and carry out the prescriptives as they apply to me and to other members of my family. I understand that there are no refunds in this program, and that if I do not complete the program, or if any member of my family fails to complete this program, its prescriptives or recommendations, it will be reported to the individual or organization that referred me and/or my family member. I release and vow not to hold Phillip L. Blansett, The Elijah Program, Counseling and Consultation Associates, Inc, or any of its officers or employees liable for any activity.

Signature ____________________________________________Date_________________ ___

(Parent/Guardian)

Signature ____________________________________________Date_________________ ___

(Student)

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