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OFFICIAL PROGRAM APPLICATION

We welcome you to the official application for Lions Gate Transformation Center. Please provide honest, detailed responses throughout this form. Your thorough answers help our team support your journey into our intensive discipleship program.

Personal Information

First name*

Last name*

Email*

Phone*

Birthday*

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Occupations*

Social Security Number*

Highest level of education*

Marriage and Relationships

Are you married or in a commited relationship*

Married

Divorced

In a relationship

If married please provide address of spouse

If in a relationship please explain the details of the relationship

Do you have children if so please list name, age, gender, marital status of each child

Legal Information

Do you currently have a Drivers License in good standing?*

Yes

No

If you do not have a drivers license or if they are currently suspended or revoked please explain.

If you currently have a drivers license please provide the license# state issued and expiration date. (If not type None)*

Pending court cases (details) . (If none please type in None)*

History of arrest or incarceration . Please include location, charges and time served. (If none please type in None)*

Current supervision, parole, or probation. Please include parole or probation officer contact information: (If none please type in None)*

Are you a registered sex offender*

Yes

No

Have you ever been convicted of sexual misconduct? If so please explain. (If not please type None)*

Have you ever been convicted of a violent crime? If so explain. (If not please type None)*

Are you currently recieving Government assistance (food, Social Security, Medicaid, disability) If disability, description. (If none please type None)*

Health Information

Please rate your physical health from 1 to 5 with 1 being poor health and 5 being perfect health *

1

2

3

4

5

Do you have any physical limitations affecting work. If so please explain if not type None*

Do you have any medical conditions requiring doctor visits? If so please explain if not type None *

Are you currently on any medications ? If so please list them below. (If not type None)*

Please list any medication needs you may have during program. (If none type None)*

Do you have a history of prescription drug misuse? If so explain if not type None*

Have you ever been hospitalized for emotional or mental health care? If so explain, if not type None*

Are you currently experiencing, or have you ever experienced, suicidal thoughts or attempts? If so please explain. ( if not type None)*

Please list any past or current health conditions (including but not limited to): Depression, cancer, diabetes, hepatitis, HIV/AIDS, mental illness, epilepsy, heart or lung conditions. (If none type None)*

Do you currently have any dental problems? If so please explain, if not type None*

Please list any addictions or behavioral issues that prompted this application. *

Works and Skills

Please list any work skills, talents or training you may have. Examples: office, computer, mechanics, construction, culinary etc.*

Applicant Certification and Signature

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that providing false or misleading information may result in denial of acceptance or dismissal from the program.

Date

Month

Day

Year

Signature

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LIONS GATE TRANSFORMATION CENTER • RENEWING LIVES • CHARACTER • FAITH • INTEGRITY • VOCATIONAL GROWTH •

CONNECT

TERMS

Physical Address: 1967 Championship Dr., Earlington, KY
Mailing Address: PO Box 130, Earlington, KY 42410
www.lionsgatetransformationcenter.org

© 2026 Lions Gate Transformation Center Residential Men's Facility.All Rights Reserved.

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ROOTED IN FAITH & PURPOSE

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