[restrict]
Application To Date My Daughter
All information you provide will be held in confidence and used strictly for the purpose of this application
PERSONAL INFORMATION
FULL NAME________________________________________ DATE OF BIRTH_______________________
EDUCATION ________________________________________________________ GPA________________
SOCIAL SECURITY #_______________________ DRIVERS LICENSE #_____________________________
HOME ADDRESS_________________________________________________________________________
CITY/STATE__________________________________________________________ ZIP_________________
HOME PHONE ________________ CELL PHONE ______________ E- mail __________________________
CURRENT EMPLOYER __________________________________________ PHONE ____________________________
SPIRITUAL HISTORY
Have you trusted Jesus as Savior?______________________ When ? ________________________________________
Who was your last Pastor ? __________________________ Where ? ________________________________________
Where do you currently attend church ? _______________________________________________________________
Name any ministries your currently involved in _________________________________________________________
PERSONAL HISTORY
Are your parents still together? _______________ How many years have they been married ? __________
Do you have siblings?____________ Names & Ages ______________________________________________________________________________________________
Rate the relationship with each of your living sibling, between 1 and 10, (10 being the best)
______________________________________________________________________________________________
When was your last romantic (dating) relationship? __________________________________________________
When did it end ?__________________________ Why ? _____________________________________________
Do you have any children? ___________ Names & Ages ______________________________________________
Have you ever been married? _________________________ How long ? ___________________
Have you ever been divorced ? ___________ Why ? _________________________________________________
Have you drunk alcohol ? _____________________ How often ? ________________ Last drink ?___________
Have you ever used drugs ? __________ What kind ? __________________________ Last high ?____________
Have you ever been convicted of a felony? ________ Explain ___________________________________________
FINANCIAL INFORMATION
Do you have any personal debt?_______ – Check one of the following
____ None ____ Less than $1,000 ____ $1,000 – $5,000 ___ $5,000 – $10,000 ____ More than $10,000
Are you paying any child support ? _____________ Are you paying alimony ? ________________________
Do you own a vehicle? ___________ Year _______ Make _________ Model ________________
Do you own a home? ____________ Address _________________________________________
Do you tithe? _____________
SEXUAL HISTORY
Have you ever had sex ? _________ If yes – How many partners? ____ Less than 5 ___ 5-10 ___ More than 10
Have you ever participated in gay sexual activity ? _____________ If yes – How many partners? ________
Have you ever been tested for STDs ___________
Are you now, or have you ever been treated for any STDs ? __________
Are you willing to be tested for STDs ______________
Are you currently sexually active ? ______________ When where you last sexually active? __________________
EMOTIONAL HISTORY
Have you ever been in therapy or counseling ? ______________________________________________________
Are you currently being counseled ? _______________________________________________________________
Are have you been prescribed medication for your emotions ? __________________________________________
Are you currently taking any prescription drugs? ____________________________________________________
LIFE GOALS
1 year plan ___________________________________________________________________________________
____________________________________________________________________________________________
5 year plan ___________________________________________________________________________________
____________________________________________________________________________________________
Life Plan ____________________________________________________________________________________
____________________________________________________________________________________________
I do attest that all the answers I have given, are the absolute truth, ________________ Date_________________
Signature _________________________________________
(c) 2013 Messenger Communications, Inc.
[/restrict]