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Educational Background:

High school: _____________________________________ Date of graduation: ________________

Further Education: __________________________________________________________________________________

Hobbies/special interests: _______________________________________________________________________________

How did you first learn about Countryside Christian Community? _________________________________________________

Have you ever been convicted of a felony?      Yes  __________        No __________

Names and addresses of children, powers of attorney, brothers/sisters or other close relationships:

(List first the person of primary contact (other than applicants) and check the appropriate boxes.POA?Receive Billings?

Name___________________________ Relationship______________ Phone_______________     Yes    No

Address__________________________________ Town______________________ State _______ Zip________________

Name___________________________ Relationship______________ Phone_______________     Yes    No

Address__________________________________ Town______________________ State _______ Zip________________

Name___________________________ Relationship______________ Phone_______________     Yes    No

Address__________________________________ Town______________________ State _______ Zip________________

Name of personal physician___________________________________________ Phone___________________________

Present condition of health (Describe any illness or physical limitations): _________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Describe any serious illness(s) you have had in the past:Hospitalization   Currently taking medication for this illness?

_________________________________________________   Yes        NoYesNo

_________________________________________________   Yes        NoYesNo

_________________________________________________   Yes        NoYesNo

_________________________________________________   Yes        NoYesNo

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