House of Destiny
PO Box 215 Votaw,
are considered for acceptance into House of Destiny based upon information required on this application, along
with the medical questionnaire. Applicants must be sincere and truthful in
their desire to seek a life of “change.”
We are totally committed to God
to present an opportunity that will help you turn your life around and discover
your true purpose in life. By completing the following application, you will enable
HOD ministry to make an investment in your future. Thank you for contacting us.
We’re here to help. STOP!(Do
not proceed any further with this application unless you are READY FOR CHANGE!!
Our desire is to help women who are ready to make a commitment of one year. We
are not a motel, not a room for rent, not a get-out-of-jail-or-prison ticket, not
a B&B, or homeless shelter. We are for REAL!! Be REAL with yourself and
House of Destiny. If you are genuinely ready for CHANGE then complete this
Please answer each section (Check all boxes)
Name of Applicant
___________________________________________ Social Security #___________
Date of Birth ________________ Age
______________ Birth State ____________
DL # ____________________
How did you hear about The House of
Immediate Contact Name:
Phone Number: __________
[ ] Own your home [ ] Motel
[ ] Rent [ ] Other [ ] Live with others (friends, relatives,
Do you have a religious affiliation? Yes /
Are you a member of a Church? Yes / No
Church Name and Address:
Status: (Circle One)
Married / Divorced / Separated / Widow /
Single How Long?
Name ____________________________Date of
Nature of Relationship
of Children: ______
Highest grade completed ______ Name of
School _____________________________________ City/State________________
GED Yes / No Vocational
Training/Certificates: (Please List) _______________________
Are you currently on Probation/Parole? Yes / No
Name of Probation/Parole
Officer_________________________ County ____________________________
Do you have fees such as restitution, etc?
Yes / No
If Yes, please
Is there a warrant for you at this
time? Yes ___ No ___
List Felony Convictions:
Date/Charge/ Sentence/ Time Served:
History of Violence:
Have you ever been involved in domestic
violence? Yes / No
As a child, did you experience or witness
domestic violence? Yes / No
History of Sexual Violence
Yes ___ No___ Assault
Yes ___ No___ Rape Yes ___ No___
you ready to make a commitment for the next year (twelve months) toward a life
ALL areas of this application should be answered.
Please list reasons why you would like to
be considered for internship at House of Destiny.
have read House of Destiny Guidelines. I agree to allow information gathered
herein to be used as deemed necessary and appropriate by House of Destiny, its
affiliates, and employees, for their ongoing ministry, whether I am accepted or
not. The information provided herein shall become property of House of Destiny.
While efforts will be made to keep information confidential, there is no
guarantee this will be achieved and you agree to hold harmless, House of
Destiny, volunteers, teachers, employees or affiliates.
I am aware that I will be in an ongoing
evaluation of my progress while at House of Destiny. If at any time the
evaluation of the staff believes that I am not taking the program seriously,
not trying to make changes, or causing too many problems, then I will be
dismissed. (Initial) _____
I am aware there is a $500 non-refundable deposit for the first month, and $500 per month for the duration of the year
I have arranged for monthly payments to
continue through the twelve months.
I have sponsorship for funding of my
I have family/friends/church who are
willing to help with funding on a monthly basis.
______________________________________ Date _____________________
Received by __________________________________