Become a Mission Client Today

PLEASE NOTE: All incoming clients are required to take a COVID-19 test before entering the program. We are more than willing to assist you in the process if needed. Please call us at 256-323-0170 if you have any questions about testing.

DOWNLOAD A PRINTABLE APPLICATION: Click Here

Step 1 of 7

Applicant Information:
First Name:*
Middle Name:
Last Name:*
Date of Birth:*
MM slash DD slash YYYY
Main Phone:*
Alternate Phone:
Last Address:
Street Address City State ZIP Code
Email Address:*
*This email will be used for general contact needs and is where you will receive a copy of your completed application as well as any necessary follow-up information.
Enter Email Confirm Email
Emergency Contact Information:
Contact Person:
Relationship:
Phone Number:
Address
Street Address City State ZIP Code
Additional Information:
Are you an alcoholic?
- Yes
- No
Are you a drug addict?
- Yes
- No
Do you have any warrants?
- Yes
- No
When was the last time you used drugs or alcohol?
Drug used:
Have you ever been charged with, or convicted of, a violent crime or sexual offense?
- Yes
- No

BACKGROUND REQUEST FORM:
Applicant's Full Name:*
I, [the above typed name], authorize Jessie’s Place to conduct an independent investigation of my driving record (MVR), background, police record and criminal history record information pertaining to me, which may be in any state or local criminal justice agency in the United States, and all public records for the purpose of confirming the information provided to the shelter.
I release the Jessie’s Place and/or its agents and any person or entity that provides information pursuant to this authorization from any and all liabilities, claims, or law suits in regards to the information obtained from any and all of the above referenced sources used. I further understand that Jessie’s Place and its agents will adhere to applicable state and federal statutes concerning the securing of information, handling, and release of the information obtained.
The following is my true and complete legal name. All information on this document is true and correct to the best of my knowledge:
Applicant's Full Name:*
7-year Address History:
Present Address:*
Street Address City State ZIP Code
How long at this address?*
“X” years or months
Former Address 1:
Street Address City State ZIP Code
How long at this address?
“X” years or months
Former Address 2:
Street Address City State ZIP Code
How long at this address?
“X” years or months
Date of Birth*
MM slash DD slash YYYY
Social Security Number:*
Driver's License Number:*
State of Issue:*
State
Applicant Signature:*
Date:*
MM slash DD slash YYYY

ITEMS TO BRING & FACILITY POLICIES
You will get a copy of this information in your email confirmation as well as an option to downloaded the from immediately after submitting the application.
MANDATORY ITEMS: Bible (study), personal hygiene products, towels and washcloths (1-week supply), underwear, socks, shower shoes, casual shoes (1 pair), work shoes or boots (1 pair), classroom clothes, work clothes, notebooks, pens, and pencils. NO jogging pants and NO luggage allowed.
OPTIONAL ITEMS: Alarm clock (no radio), radios with headphones only, tobacco products (2-week supply), individually wrapped snacks, canned drinks, pillow, and clothes hangers.
All medical, legal or personal appointments must be approved by the Director prior to appointment. (Clients are responsible for providing their own transportation to and from said appointments.)
Note: Clients are required to wear shirts with collars for both class-room and church dress. Shorts are only permitted during outside recreation. Shorts are not permitted for any work detail or classroom activities. Bring enough clothes to last for at least two weeks. Client’s laundry will be done weekly.
Clients and their belongings are subject to search upon entry to Royal Pines . In the event any addictive substance is found during the search this evidence will be used for prosecution.
All medication must be relinquished to a staff member upon entry. Clients will be given access to their medication (both prescription and OTC) dailye.
Clients are allowed to have cash (for drink machines).
Medication: FDA scheduled drugs are NOT allowed. Please ask your doctor to prescribe medications which are listed on our “Acceptable Medication List.” All OTC and prescription medications MUST be turned in to office upon arrival.
Legal Issues: If you have any legal issues such as probation, parole, and/or court dates please have all contact information and dates with you upon arrival. You will need to provide names, phone and fax numbers, and email information so we can properly inform each agency. Legal backgrounds are checked before entering the program. If you have any outstanding misdemeanor or felony warrants you will not be allowed to enter the program. These legal matters must be taken care of before admittance. In addition, any persons with a history of sexual or violent crimes cannot be accepted.
Detoxification: If you are withdrawing from alcohol, benzodiazepines, or barbiturates you are required to bring proof of medical detoxification before you can enter the program at the Jimmie Hale Mission.
AGREEMENT:*
I agree that I have read and understand the above information regarding items and policies.

Client Application

Jessie’s Place

Step 1 of 7

Applicant Information:

Emergency Contact Information:

Additional Information:

Health Information:

RELATIONAL INFORMATION:

CHILDREN LIVING WITH YOU:

CLIENT POLICY AGREEMENT:

TRNASPORTATION INFORMATION:

DISCLAIMER:

CLIENT POLICY AGREEMENT:

BACKGROUND REQUEST FORM:

7-year Address History:

ITEMS TO BRING & FACILITY POLICIES

Shepura

Jessie's Place

Royal Pines