We must receive this form to complete your registration.

Please mail registration panel, this application and payment to: Embracing Life Ministries
1443 E. Washington Blvd. #635, Pasadena, CA 91104-2650
Questions or information call/fax: 626-798-7398
www .E mbracing L ife . us

CONFIDENTIAL APPLICATION FORM: Please fill out the intake with as much detail as possible. These
questions help us to place you in a small group. If needed, attach an extra sheet for explanation.
Your responses will be kept strictly confidential.
Date: __________________________
Name: _________________________________________________________________________ Age:______
q Male q Female q Single q Married
Address: __________________________________________________________________________________
City: ____________________________________________________________ State: ____ Zip: ___________
Home phone: ________________________________ Cell phone: ____________________________________
e-mail: (print clearly) ________________________________________________________________________

Are you a Christian? q Yes q No For how long? ____________________________________________

Please describe your illness/condition:

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What treatment and/or healing means have you sought so far?
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IN CASE OF EMERGENCY, PLEASE CONTACT:

Name: _________________________________________________ Home Phone: ____________________________
Address:_______________________________________________________________________________________
City:__________________________________________ State: ______Zip: ___________ Relationship:_____________
Business: __________________________________________________________________________________

Are you currently on any medication? q No q Yes If yes, are there specifics or protocols we
should know about in case of an emergency: e.g., daily insulin shots etc.?
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Are you currently in therapy, seeing a counselor or in any type of support group for issues related to your
condition? q No q Yes If yes, explain:
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Have you ever been hospitalized for problems related to your condition? q No q Yes If yes, explain:
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Is there other background information about your family/history or current living situation which you
feel would be important for us to know: abusive home environment, live alone, physical impairment w/
transportation needs, recently divorced, death of spouse, etc….?
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What is your current church affiliation, if any: _________________________________________________

Are you currently serving in any ministry or church related group? If so, please describe:
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If accepted, what expectations do you have in attending ELS?

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Thank you for taking the time to provide this information.