Program ApplicationFill out the form below. All info will be submitted to our program team. Name * First Name Last Name Date of Birth * MM DD YYYY Sex * Who is completing this form? * Yourself Someone on behalf of the applicant Email Address * Phone Number * (###) ### #### Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Best way to contact you * Phone Email Have you ever stayed at WRM before? * Yes No How did you hear about the program? * Jail Probation Family / Friend Self / Research Other Reason for wanting to enroll into WRM's program * Are you currently or soon to be experiencing homelessness? * Yes No Are you fleeing from someone? * Yes No What is your marital status? * Married Single Divorced Are you required to pay child support? * Yes No Are you currently receiving any form of income? * Yes No Are you currently employed? * Yes No Are you currently in school or in a training program? * Yes No Are you a veteran? * Yes No Have you been prescribed any medications for a physical and/or mental health diagnosis? * Yes No Do you have a mental health diagnosis? * Yes No Have you ever been arrested? * Yes No Have you been charged with any violent crimes? * Yes No Have you been convicted of a crime involving children or the elderly? * Yes No Are you a sex offender? * Yes No Do you have any pending charges? * Yes No How can we pray for you? * Disclaimer * Winchester Rescue Mission (WRM) is not a medical or psychiatric facility. To help us make informed decisions and ensure the best fit, we may request medical or mental health information. If later it's found that our program isn't the right match due to undisclosed medical or psychological concerns, we may recommend alternative options or collaborate with referring agencies. Please know your well-being is our top priority. I understand and agree to the above statement Type your name below * This will serve as your electronic signature Thank you! Your application has been sent to our program team.
