Men's 180 Omaha Application 180 Omaha is a ministry for people with an evident desire to become disciples of Jesus Christ. For further questions, email: email@example.com Step 1 of 8 12% Name* First Last Date of Birth* Month Day Year Gender* Male Female Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone Number*Parents Name & Contact Information (if applicable)Marital Status* Single Married Divorced Widowed List Reason for Divorce* Please click Next to continue to the next page. Did you graduate from High School? If so, where and when? How many Children do you have? What are their ages?*Do you owe any alimony/child support? If so, how much?* Did you attend College? What's your major? When did you attend? Degree earned? Did you attend trade school? If so, when and what is your trade? What is your usual occupation?* Are you currently working? if so, where? If not, why?* The next section is about your military background, if applicable. Please click Next to continue. Are you a Veteran?* Yes No How long were you in the Service? Date If Discharge Month Day Year Type of Discharge Honorable Dishonorable Please explain dishonorable discharge The next set of questions relate to your overall health. Please click Next to continue. What is the state of your health? Excellent Good Fair Poor List all major illnesses and/or surgeries that you have had:*When were you last tested for HIV?* When were you last tested for Hepatitis C?* Do you smoke or chew any form of tobacco (i.e. cigarettes, dip, vaporizer, etc.)?*Please select an optionYesNoAre you currently taking any prescription or our the counter medicine? If so, what are you taking and what is the dosage?*Have you ever considered committing suicide? When? Have you ever attempted suicide? When? Why? The next set of questions relate to substance abuse. Please click Next to continue. What is your drug of choice? At what age was your first drinking/drugging experience? What is your longest period of sobriety? When did you last drink or get high? What did you drink/use?* Please list any rehabilitation centers you have attended, when you attended, and how long it was:* The next section is about your arrest record, if any. Please click Next to continue. Have you ever been arrested?*Please select an optionYesNoNumber of times arrested* Please list from newest to oldest all charges, date of arrest, and time served for each:Charges* Date of Arrest* Month Day Year Time Served* Add another? Yes Charges* Date of Arrest* Month Day Year Time Served* Add another? Yes Charges* Date of Arrest* Month Day Year Time Served* Add another? Yes Charges* Date of Arrest* Month Day Year Time Served* Add another? Yes Charges* Date of Arrest* Month Day Year Time Served* Have you ever been charged with any sexual crime?* Yes No Are there currently any charges pending against you at this time?* Yes No Please list what the charges are* Do you have any open warrants for your arrest?* Yes No Are you currently on Probation/parole?* Yes No How long?* Name of Probation/Parole officer and phone number The next section is about your spiritual life. Please click Next to continue. What is your church affiliation?* How often do you read the Bible and pray?* Are you saved?* Yes No Briefly describe your testimony and your walk with Christ since that time:* Please click Next to continue to the final page. Personal Reference #1* Please list name and phone numberPersonal Reference #2* Please list name and phone numberPersonal Reference #3* Please list name and phone numberDo you understand that 180 Omaha requires a minimum of 4 months commitment to the ministry?* Yes No Will you need to detox before coming into the ministry?* Yes No Are there any dates/events coming up that you would be requesting to leave the property during your commitment? (i.e. probation, court dates, etc.)*If you were to be accepted into 180 Omaha today, is there anything not listed above that we would need to know? Failure to disclose important information could result in acceptance into 180 Omaha being denied or dismissal if you have already been accepted.*How did you hear about 180 Omaha?*CAPTCHACommentsThis field is for validation purposes and should be left unchanged.