Application

Full Name

First

Last

Date of Birth

Age

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Confirm Email

State of Residence

Reason for Attending

Primary Language

Secondary Language(s)

Church Name

Church Membership Status

Pastor’s Full Name

Pastor’s Phone Number

Baptism Date

Are you a former student of GWPMS?

Have you attended rehab before?

Semester Ministry Relationship

What program are you applying for?

Are you in a relationship?

How did you hear about us?

Ministry Experiences or Abilities

Goals for the Semester

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship

Deposit Requirement

Price: $500.00

A deposit is required to secure your place in the program. This deposit ensures your spot and will be applied towards the total tuition

Single Item

Price: $50.00

A application fee is required and is non-refundable

Payment Information

All total

$0.00