Print this page, fill in the blanks sign and procure a signature of your Ecclesiastical Adjudicatory Authority and Postal Mail it to:
1621 Eagle Trace Drive, Mount Juliet, TN 37122-7428
Blansett@mail.serve.com
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
CERTIFIED CHRISTIAN MENTOR(tm) APPLICATION
1621 Eagle Trace Drive
Mount Juliet, TN 37122-7428
(615) 758-7568
Husband's Name:
__________________________________________________________
Occupation: ___________________________________________
Wk Ph:(__________) email address: ___________________
Wife's Name:
_____________________________________________________________
Occupation: ___________________________________________
Wk Ph:(__________) email address: ____________________
Address: ______________________________________________
Hm Ph:(__________)
City: __________________________________State:____
Zip:___________________
Birthdates: Husband________ Spouse________
Years at current residence:____
Approx. ages (circle): 30-40 41-50 51-60 over 60
Church Affiliation: ___________________________
Church Ph:(______________)
Are you members? ______ Church position held:
____________________________
No. years attended: ______ Church
address:_______________________________
City: ___________________________________State:____
Zip:__________________
Pastor's Name: ____________________________________
Hm Ph: (______________)
Has either husband and/or wife been charged with or convicted of any offense involving a minor?
(circle): Yes No
Statement by husband and/or wife on reasons for wanting to be become Mentors:
_________________________________________________________________ _________ _________________________________________________________________ _________
Signatures Husband: ___________________________
Wife:_____________________
Date: _________________
Pastor's recommendation:
_________________________________________________ _________________________________________________________________ _________ _________________________________________________________________ _________
Pastor's Signature: _________________________________
Date: ______________
------------------------do not write below this line----------------------
Interviewed by:_______________________ Position __________
Date __________
Accepted: _____ Date __________
Signature_______________________________
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