StraightWay Training Center

Here, you can fill out and submit your application, right from your computer. The application process is not a short one. The application itself is 12 pages. Click on each "drop-down" menu to view all areas of the application to be sure that you allocate enough time to finish. You cannot save changes and come back later, so it is advised to complete all of the questions in one sitting. Some of the fields are required. This means that you cannot submit an incomplete application. Thank you for your interest in the program.

I. General Information

Full Name:
Maiden Name:
Any other names ever used:
Email Address:
Current Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Previous Address:
City:
State:
Zip:
Driver's License #:
State Issued in:
Social Security #:
Birthdate: (00/00/0000)
Age:
Sex:	Male Female
Race:
Weight:
Height:
Describe any other distinguishing marks:
Marital Status
Spouse's Full Name:
Spouse's Address (If not the same as yours):
City
State
Zip
Home Phone:
Work Phone:
Date Married:
If separated or divorced, please give a date:
Full name of ex-spouse:
Home Phone:
Work Phone:
Address:
City:
State:
Zip:
Full name of ex-spouse:
Home Phone:
Work Phone:
Address:
City:
State:
Zip:
Referred to StraightWay by:
Relationship to you: (friend, relative, etc.)
His/Her Address:
City
State:
Zip:
His/Her Occupation/Position:
What relation/contact has this person had to StraightWay before?
In case of emergency, notify:
Relationship to you:
His/Her Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Life Insurance Policy #:
Company:
Address:
City:
State:
Zip:
Phone:
Health Insurance Policy #:
Company:
Address:
City:
State:
Zip:
Phone:
Are you eligible for and/or receiving:	Welfare Unemployment Disability Workman's Comp Other Income
Please Explain:
Have you ever applied for or received food stamps?	Yes No
If yes, where?
Do you have any debts?	Yes No
If yes, list them below (Owed to; Address; Phone #; Total Amount; Monthly Payments):
Have these debtors been contacted as to your plans to enter the program, and have arrangements been made with them regarding the debts?	Yes No n/a
Explain:

II. Personal Information

How long have you been on your own?
Reason for leaving:
What kind of problems did you have living at home?
What are your present living conditions?
With whom do you live?
Where:
How were you supported?
What significant changes have occurred in your life recently (behavior, employment, activities, etc.)?
Describe your relationship with your husband/wife/boyfriend/girlfriend:
Do you have any children?	Yes No
If yes, list below: Children's Names; Birth-dates; Ages; Other Parent's Name; Child Support; Custody (Me/other); Applying with you?
Are you willing and able to come into the program ahead of your children should there be a waiting list at the time of your application?	Yes No n/a
If so, who would most likely be keeping your children until a room opened up? (Name):
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Relation to you:
Are you willing and able to come into the program ahead of your children should there be a waiting list at the time of your application?	Yes No n/a
Do you receive alimony payments?	Yes No n/a
Amount:
To your knowledge, has anyone in your family committed incest?	Yes No
When:
Who:
Are you an American citizen?	Yes No Native Naturalized
If no, please explain:
Visa for:
Expiration Date:
List any hobbies you now have:
Last school attended:
Last grade completed:
Technical/Vocational schools attended:
Sexual orientation:	Heterosexual Homosexual Bisexual Transsexual
How recently involved?
Have you ever engaged in homosexual activities?	Yes No
How frequently?
Have you ever masturbated?	Yes No
Do you now masturbate?	Yes No
How frequently?
Have you ever had an abortion?	Yes No
Explain:
Have you ever served in any branch of the military?	Yes No
Branch:
Type of work:
Date of service:
Discharge date:
Manner of discharge:	Honorable Less than Honorable Dishonorable
Check any work skills you have from the following list.	Carpentry Typing General Mechanical Printing Teaching Plumbing Cooking Auto Mechanics Masonry Electrical Farming Auto Body Work Nursing Electronic Livestock Sewing Child Care
If you have any skill not listed above, please specify:

III. Personality Information and Mental Health History

Check any of the following words that best describe you now:	Active Easily influenced Lonely Sensitive Likeable Nervous Bitter Valuable Worthless Submissive Moody Ambitious Disillusioned Happy Follower Calm Often blue Self-confident Persistent Angry Good-natured Serious Impatient Impulsive Leader Introvert Excitable Imaginative Self-conscious Quiet Hard-boiled Shy
Other (Specify):
Have you ever felt that people were watching you?	Yes No
Explain:
Have you ever had suicidal tendencies?	Yes No
Explain:
Do people's faces ever seem distorted?	Yes No
Explain:
Do you have difficulty hearing?	Yes No
Explain:
Do colors seem:	Too bright? Too dull?
Are you able to judge distances?	Yes No
Have you ever had hallucinations?	Yes No
Is it easy for you to express your feelings?	Yes No Sometimes
Do you enjoy being with other people, or would you rather be alone?	Enjoy being with other people Would rather be alone
Are you afraid of being in a car?	Yes No
Do you have trouble sleeping?	Yes No
Have you ever had psychiatric care?	Yes No
For what?
Where?
When?
Doctor's Name:
Address:
City:
State:
Zip:
Phone:
Response:
For what?
Where?
When?
Doctor's Name:
Address:
City:
State:
Zip:
Phone:
Response:
For what?
Where?
When?
Doctor's Name:
Address:
City:
State:
Zip:
Phone:
Response:
Do you have access to the complete records of any mental health history, including any psychological exams or social history?
Have you ever been in a religious or non-religious program before? Please list below.	Religious Non-religious n/a
Program Name:
Date:
City & State:
Reason for leaving:
Program Name:
Date:
City & State:
Reason for leaving:
Program Name:
Date:
City & State:
Reason for leaving:
Program Name:
Date:
City & State:
Reason for leaving:
Program Name:
Date:
City & State:
Reason for leaving:
Program Name:
Date:
City & State:
Reason for leaving:
Have you ever been involved with StraightWay before?	Yes No
Why did you leave?	Dismissed Released Completed program Graduated
Have you given doctors or agencies involved in previous treatment your written consent to release the above mentioned confidential information to the StraightWay Training Center?	Yes No
If yes, when? If no, please do so as soon as possible, because we must have these records before your interview can be set.

IV. Parental Family History

Natural Father's name:
Home phone:
Work phone:
Address:
City:
State:
Zip:
Natural Mother's name:
Home phone:
Work phone:
Address:
City:
State:
Zip:
What is your current relationship with your natural parents?	Excellent Good Fair Poor Extremely poor None
If "poor", "extremely poor", or "none", tell why:
When did you last see them?
When did you last live at home?
Stepfather's name: (If applicable)
Home phone:
Work phone:
Address:
City:
State:
Zip:
Stepmother's Name (if applicable):
Home phone:
Work phone:
Address:
City:
State:
Zip:
What is your current relationship with your stepparents?	Excellent Good Fair Poor Extremely poor None n/a
If "poor", "extremely poor", or "none", tell why:
When did you last see them:
When did you last live at home?
Foster Father's name:
Home phone:
Work phone:
Address:
City:
State:
Zip:
Foster Mother's name:
Home phone:
Work phone:
Address:
City:
State:
Zip:
What is your current relationship with your foster parents?	Excellent Good Fair Poor Extremely poor None n/a
If "poor", "extremely poor", or "none", tell why:
When did you last see them?
When did you last live at home?
Are you adopted?	Yes No
If you were raised by anyone other than your own parents, briefly explain:
Are your parents still living? (Check for 'yes')	Father Mother
Father's religious affiliation:
Mother's religious affiliation:
Is your father a Christian?	Yes No
How long?
How often does your father attend church per month?
Is your mother a Christian?	Yes No
How long?
How often does your mother attend church per month?
Father's occupation:
Mother's Occupation:
Are your parents:	Married Divorced Separated Remarried Still living together
If they are not still living together, the cause of the separation was:
When did they separate?
Rate your parent's marriage:	Very happy Happy Average Unhappy Very unhappy
As a child, did you feel closest to:	Father Mother Someone else
How many older brothers do you have?
How many older sisters?
How many younger brothers?
How many younger sisters?
What is your current relationship with your siblings:	Excellent Good Fair Poor Extremely poor None n/a

V. Legal Status

Have you ever been arrested?	Yes No
How many times?
Date:
Charge:
Plea:	Guilty Not Guilty
Verdict:	Convicted Not Convicted
Sentence:
Time in jail:
Date:
Charge:
Plea:	Guilty Not Guilty
Verdict:	Convicted Not Convicted
Sentence:
Time in jail:
Date:
Charge:
Plea:	Guilty Not Guilty
Verdict:	Convicted Not Convicted
Sentence:
Time in jail:
Date:
Charge:
Plea:	Guilty Not Guilty
Verdict:	Convicted Not Convicted
Sentence:
Time in jail:
Date:
Charge:
Plea:	Guilty Not Guilty
Verdict:	Convicted Not Convicted
Sentence:
Time in jail:
Have you ever been on probation?	Yes No
Are you now on probation?	Yes No
How long?
Time remaining:
You report to your probation office:	By mail In person
How often?
Name of probation officer:
Phone number:
Address:
City:
State:
Zip:
Have you ever been in prison?	Yes No
Date:
Where:
Date:
Where:
Date:
Where:
Date:
Where:
Are you on parole?	Yes No
You report to the parole office:	By mail In person
Name of parole officer:
Phone:
Address:
City:
Street:
Zip:
Name of lawyer:
Home phone:
Office phone:
Address:
City:
State:
Zip:
Are you currently in prison?	Yes No
Address of prison:
City:
State:
Zip:
SPN #:
Cell #:
Phone #:

VI. Employment

What is your trade or profession, if any?
Name of last employer:
Address:
City:
State:
Zip:
Phone:
Reason for leaving:
How many different jobs have you held in the past year?
Reasons for leaving:
What kind of job or trade would you like to learn?
List your work history for the last three years (Employer, Job description, Date started & ended):

VII. Physical Heath History

What provisions for medical expenses can or have been made through your family or sponsors?

Do you have any physical ailments or handicaps that would inhibit normal manual labor?

Yes
No

Explain:

When were your eyes last checked?

Results:

Do you have any eye problems?

Do you wear prescription glasses?

Yes
No

Are you now?

Yes
No

When were your teeth last checked?

Do you have any teeth problems?

Yes
No

Please Explain.

Do you currently have any of the following?

Severe or persistent headache
Blurred Vision
Double Vision
Blindness
Pain in the eyes
Red or inflamed eyes
Watery eyes
Hearing loss
Runny ears
Ringing in ears
Frequent sneezing
Hay fever
Sinus trouble
Persistent cough
Coughing blood
Asthma
Night sweats
Wheezing
High blood pressure
Low blood pressure
Severe chest pain
Racing of heart
Shortness of breath
Swelling of ankles
Leg cramps
Rheumatic fever
Heart trouble
Poor appetite
Nausea
Vomiting
Stomach ulcer
Vomiting blood
Frequent indigestion
Stomach pain
Yellow jaundice

Gas pain
Belching
Diarrhea
Scarlet fever
Measles
Chicken pox
Mumps
Whooping cough
Smallpox
Typhoid fever
Cancer
Anemia
Syphilis
Gonorrhea
Diphtheria
Hepatitis
Tuberculosis
Pneumonia
Nervous breakdown
Goiter
Arthritis
Blackout spells
Convulsions
Backache
Fatigue
Dizziness
Excessive fatigue
Are you nervous?
Are you depressed often?
Do you worry?
Do you sleep well?
Are you excessively sleepy?
Do you cry easily?
Excessively dry skin
Excessive sweating
Frequent rash
Frequent boils
Severe itching

Have you ever had any of the following in the past?

Blood in urine
Pus in kidneys
Frequent urination at night
Burning upon urination
Loss of bladder control
Frequent kidney infections
Do you strain to urinate?
Kidney stones
Scarlet fever
Measles
Chicken pox
Mumps
Whooping cough
Smallpox
Typhoid fever
Cancer
Anemia
Syphilis
Gonorrhea
Diphtheria
Hepatitis
Tuberculosis
Pneumonia
Nervous breakdown
Goiter
Arthritis
Blackout spells
Convulsions
Backache
Fatigue
Dizziness
Excessive fatigue
Are you nervous?
Are you depressed often?
Do you worry?
Do you sleep well?
Are you excessively sleepy?
Do you cry easily?
Excessively dry skin
Excessive sweating
Frequent rash
Frequent boils
Severe itching

List your allergies:

List drugs to which you are allergic or sensitive:

List any other past or present illnesses not listed:

Do you have epilepsy?

Yes
No

What type:

Have you had a blood transfusion?

Yes
No

List medicines you take (bring medicines with you), and what prescribed for:

FOR WOMEN ONLY.

Your age at time of first period:

Days between periods:

Length of period:

Flow:

Heavy
Average
Light

Any bleeding between periods?

Yes
No

Number of pregnancies:

Number full-term:

Number of miscarriages:

Weight of largest baby:

Any complications with pregnancy?

Have you had Menopause (change of life)?

Yes
No

When?

Are you pregnant?

Yes
No
Maybe

If maybe, why do you think so?

Have you ever had an abortion?

Yes
No

Explain each time:

List all surgery you have had with dates:

Do you have any special diet requirements?

Yes
No

Explain:

VIII. Family History

Father's: Age; Condition of Health; Age at Death; Cause of Death
Mother's: Age; Condition of Health; Age at Death; Cause of Death
Sister(s)': Age; Condition of Health; Age at Death; Cause of Death
Brother(s)': Age; Condition of Health; Age at Death; Cause of Death
Childrens': Age; Condition of Health; Age at Death; Cause of Death

IX. Drug History

Why did you become involved with drugs?
I depend on drugs to (check which ones apply to you)	Cope with life For pleasure To escape reality To be "in" Other
If "other," please explain:
Habit cost per day:
Longest period clean:
Drugs used only once:	Alcohol Barbiturates (downers) Amphetamines (uppers) Heroin Cocaine Hallucinogenics Opium Glue Tobacco Marijuana Crack Other
If "other," explain below:
Drugs used several times:	Alcohol Barbiturates (downers) Amphetamines (uppers) Heroin Cocaine Hallucinogenics Opium Glue Tobacco Marijuana Crack Other
If "other," explain below:
Drugs used regularly:	Alcohol Barbiturates (downers) Amphetamines (uppers) Heroin Cocaine Hallucinogenics Opium Glue Tobacco Marijuana Crack Other
If "other," explain below:
Strung out:	Alcohol Barbiturates (downers) Amphetamines (uppers) Heroin Cocaine Hallucinogenics Opium Glue Tobacco Marijuana Crack Other
If "other," explain below:
First time to use above specified drugs (ex: Alcohol - 1/1/01):
Last time to use above specified drugs (ex: Alcohol - 1/1/01):

X. Spiritual

Have you ever committed your life to God?	Yes No
Date:
Place:
What were the circumstances that led to this?
Your denominational preference:
How often do you attend church?	Never Occasionally Regularly
Are you a member of any church or religion?	Yes No
Which one?
Pastor's name:
Phone:
Address:
City:
State:
Zip:
What church did you attend as a child?
How many years:
How often did you attend church as a child?	Never Occasionally Regularly
Which denomination?
How old were you when you stopped attending?
Why did you stop?
How many times have you backslid?
Do you believe in God	Yes No Uncertain
Do you ever pray?	Never Occasionally Often
Are you saved?	Yes No Not sure what you mean
How often do you read the Bible?	Never Occasionally Often
Do you read books of other religions instead of the Bible?	Never Occasionally Often
Which ones?
What recent changes (if any) have you had in your religious life?
Have you ever been involved in the occult?	Yes No
List occult involvement:	Ouija boards Horoscopes Witchcraft Voodoo Palm reading Satanic worship Divining Tarot Cards Seances Fortune telling Spell casting Other
If "other," please explain:
Have you ever been involved in cults, such as Christian Science, Jehovah's Witnesses, Mormons, Scientology, TM, Eastern religions, etc.?	Yes No
Explain:
Explain your need of God, what your standing with Him now is (good or bad relationship, no relationship, etc.):
As you see it, what is the main problem? Why are you here?
What have you done about it?
What are your greatest needs, in order of priority?
Why do you wish to be admitted to the StraightWay Training Center program?
What are you expecting or believing God to do in your life through this program?
Are you expecting God to do it all ("zap" you), or do you believe it will take some effort, commitment, and sacrifice on your part? Describe what you're willing to do, or what you think is required of you:
What would you like to do after you leave the StraightWay Training Center?

XI. VERIFICATION

I certify that all the information on this application is true and accurate to the best of my knowledge, and has been fully completed by me in my own hand. I understand that any false or incomplete information may result in disqualification of my application for entrance.	I Agree I Do Not Agree
Name of person filling in forms (if other than applicant):
Relation to applicant:
The reason why the applicant was unable to fill out the application for him/herself is:
Do you understand that learning disabilities severe enough to prevent the applicant from completing the application may disqualify the applicant from eligibility in the program?	Yes No
It is hereby understood that the StraightWay Training Center can not and will not be held responsible for any personal property left, lost or stolen while in the StraightWay Training Center program.	I Agree I Don't Agree
I agree that any property or money left at the StraightWay Training Center over thirty days from my departure date, announced or unannounced, becomes the property of the StraightWay Training Center.	I Agree I Don't Agree
It is further understood that I release the StraightWay Training Center from all financial responsibilities in case of accident, injury, illness, or other imponderable misfortune. I understand that my processing fee is non-refundable.	I Agree I Don't Agree
I authorize the StraightWay Training Center to use my photograph and/or name in promotional material and programs presented by the StraightWay Training Center.	I Agree I Don't Agree

***By submitting this application, I a am signifying that:
- I have read the StraightWay Requirements booklet in is entirety.
- All Information I have provided is accurate and truthful.

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