Student Application Select ALL that apply(Required) Mr. Mrs. Ms. Miss. Pastor Widow SingleParent Non U.S. Citizen Name(Required) First Last Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Church(Required) Spouse Phone(Required)Work PhoneFaxEmail(Required) Occupation Age(Required) 1. Which of the following Elijah House books have you read? Restoring the Christian Family God’s Power to Change Growing Pains Elijah Task Transformation of the Inner Man The Renewal of the Mind Why Some Christians Commit Adultery Transforming of the Inner Man Letting Go of Your Past Deliverance and Inner Healing Healing the Wounded Spirit Life Transformed Healing Victims of Sexual Abuse Why Good People Mess Up 2. Which of the following Elijah House Classes have you completed? Course 201 (Basic 1) school Course 202 (Basic 2) school Healing of Trauma Seminar Prophetic School Other Elijah House Seminars/Classes Other 3. How long have you been a Christian? Date of Salvation MM slash DD slash YYYY 4. Please give a brief account of when and how you became a Christian.5. How are you presently serving the Lord?6. Are you in a relationship with a spiritual leader in a pastoral role who knows you, is aware of your spiritual condition, and can hold you accountable? Yes No 7. Are you presently ministering to others? Yes No Lay/Church Lay/Private Professionally If not, do you plan to do prayer ministry after completing this training? Yes No Don´t Know 8. What is your primary reason for attending this school?9. Are you receiving prayer ministry or counseling at this time? (If so, briefly explain.) Yes No Briefly explain. 10. Have you been diagnosed with Dissociative Identity Disorder, Borderline Personality Disorder, or a victim of Ritualized Abuse? Yes (please explain and describe your treatment plan briefly.) No Yes. Briefly explain. 11. Special Needs or requests (Select what applies, and briefly explain) Allergies Medication Disability Dietary Other None Briefly explain Personal responses to teaching and small group interaction may include (but is certainly not limited to) some of the following: expressions of anger, prejudices and resentments, apprehension, anxiety, insomnia, depression, dissociation, etc. Note: If a crime is confessed in small group during the course of the school, the Facilitator/leader of your small group will need to report it to the Director/Facilitator of the school. The Director/Facilitator of the school, in accordance with the laws of that state, may need to report it to the proper authorities. Because of time restraints, all of your personal life issues will not be dealt with during the course of the school. This is a life-long process. If you feel there are already significant life issues that need to be addressed, ministry or counseling prior to your enrollment in the school is advisable and always beneficial. If you have been seeing a counselor, we ask that you discuss the school with your counselor and receive their approval. Their signature is required below. Having accepted the school enrollment information, requirements outlined in this application, and the Elijah House Facilitated School Booklet, I prayerfully submit my application. I agree to respectfully abide by the determination of Elijah House as to the suitability of my attendance at this time. I agree to indemnify and hold Elijah House and any Host Facility harmless for any of my personal responses to the teachings and small group time during the school. I also agree to indemnify and hold Elijah House and any Host Facility harmless for any costs in time, travel, accommodations, or other incidentals, should the school be canceled, my acceptance be delayed, or I am asked to discontinue the course to seek ministry before continuing at another time. I agree to maintain the confidentiality of what is shared by leaders and students in class and small groups. I understand that I may be filmed or photographed during the event for use in future training events and advertisements for display without using my name, and I give permission for use of my image/picture in this way. I understand that my signature testifies that all information provided is true, that I accept all terms of enrollment, and will provide sufficient funds in a timely manner for my participation in the school. Applicant’s Signature Date MM slash DD slash YYYY Spouse’s Signature Date MM slash DD slash YYYY Counselor Name (if applicable) Signature Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneCommentsThis field is for validation purposes and should be left unchanged. 18136
