Northeast Michigan DeColores Ministry
CONFIDENTIAL Candidate Registration
The DeColores Weekend is open to all who are 18 years of age or older. Married couples are strongly encouraged to
attend consecutive DeColores Weekends. It is recommended, but not required, that the husband attend first.
Candidate Information: PLEASE PRINT CLEARLY AND RESPOND TO ALL QUESTIONS
Personal Information:
First Name: ___________________ Last Name: ______________________ Prefer to be called: ________________________
Address:_________________________________________ City:____________________________ State:_____ Zip:________
Home Phone: (_____) _____- ________ Work Phone: (_____) _____ - ________ Cell Phone: (_____) ____ - ______
Email: __________________________________ Gender: Male: ____ Female: ___ Birth date: _______________ (mmddyyyy)
Marital Status: Single ___ Married ___ Widowed __ Divorced___ Separated___ If widowed, divorced or separated, how long? ______
Spouse’s Name: __________________ Has your spouse attended a DeColores or similar 3 day Weekend? Yes ___ No ____
Church: ______________________________________________________
Pastor’s Name ______________________________
Are you baptized? Yes ___ No ___ Has the DeColores Weekend been explained to you? Yes_____ No ______
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Physical or health limitations/needs: (this information is to help us serve your needs and does not restrict you from attending
the weekend)
Mobility: Check any that you use: Walker_____ Wheelchair______ Other_______________________
Do you need to use a ramp or elevator? Yes___ No___ Do you require any assistance? Yes____ No ____ If “Yes” please indicate what
type of assistance you will need ___________________________________________________________________________
Special Dietary Needs: (Special dietary requirements may require the candidate or sponsor to provide the dietary food items for the
weekend.) Diet type: Regular _____ Low sodium ____ Gluten free _______ Vegetarian ________Vegan ______ Other _________
Do you have any food allergies? Yes____ No____ If “Yes” please list foods you are allergic to: _______________________________
___________________________________________________________________________________________________________
Medical conditions: Are you diabetic? Yes____ No_____ If “Yes” are you insulin dependent? Yes____ No______
Insulin: By injection ______ Oral medication____ When do you check your blood sugar level? _______________________________
Do you have any heart or lung conditions that we should know about? Yes____ No_____
If “yes” briefly explain: ____________________________________ _____________CPAP machine Yes ______ No________
Do you have any other serious health problems that we need to be aware of? Yes_____ No_____ If so, please explain:___________
___________________________________________________________________________________________________________
Medications: Please indicate any medications you are currently taking (list any additional medications on separate sheet of paper)
Medication
Dosage
1 Daily (time?)
2 or more times daily (times?)
Are there any emotional or personal stresses that you are presently resolving? Explain Briefly: ______________________________
__________________________________________________________________________________________________________
Please give a brief, frank idea of why you wish to attend a DeColores Weekend: __________________________________________
__________________________________________________________________________________________________________
Upon completion of this form, please return it to your sponsor along with your $25.00 application fee (and optional donation) so
that he or she may complete the bottom half. Checks should be made payable to “Northeast Michigan DeColores Ministry”.
______________________________________________________
Applicant’s Signature
Update 11/10/2015
________________________________________________________
Pastor’s Signature (requested but not required)
>>>>>>>>>>>>>>>>>SPONSOR --- PLEASE FILL OUT COMPLETELY<<<<<<<<<<<<<<<<<<<<<<
1. How long have you known your candidate? ____________ Do you feel that you know this candidate well enough to
fulfill your duties as a sponsor? __________________________________________
2. What are your reasons for recommending this candidate?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
3. To your knowledge, does this candidate have any dietary, physical or emotional problems/limitations that would affect
participation on a DeColores Weekend or of which we should be aware? Yes ___ No ___ If Yes, please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
4. ESSENTIAL INFORMATION: Sponsors, please circle the qualities that best describe your candidate.
(Complete A, B, & C)
A. Shy or Outgoing
B. Quiet or Talkative
C. Is a Leader or Is a Follower
“I am familiar with the qualifications and responsibilities of a sponsor and I am prepared to accept these obligations:”
Sponsor’s Name (printed): ________________________________________________
Email: ______________________________________________
Address: ___________________________________ City: __________________________ State: ____ Zip: __________
Home Phone: (_____) ______ - ________ Work Phone: (______) ______ - _________ Cell: (____) ______-________
Sponsor’s Signature: __________________________________ Date: _____/_____/_____
Note: DeColores is a non-profit organization and is operated solely on donations. It is the sponsor’s
responsibility to mail the completed application along with the $25.00 application fee. If the candidate
should turn down three invitations to attend a weekend, it will be necessary to submit a new application and
application fee.
Mail Complete application and $25 fee to:
FOR INTERNAL USE ONLY:
Shirley Schmoock
1489 S. AuSable Trail
Grayling, MI 49738
989-889-5019 (cell)
989-348-5132 (home)
email: [email protected]
Date Rec’d ____/____/____ Fee Paid
1st Mailing ____/____/____ Response ____ Date ____/____/____
2nd Mailing ____/____/____ Response ____ Date ____/____/____
3rd Mailing ____/____/____ Response ____ Date ____/____/___
Update 11/10/2015