Please note: ALL fields are required before you can submit this form. If a field does not apply, you can use "N/A".


If so, explain and give amounts and source of income:

*** If there are any diagnosed mental or physical disabilities in your your family, please send documentation. A DOCTOR should sign it.***

Grace Place Ministries, Inc. reserves the right to require documentation for any of the information required on this application, and any additional information that will be helpful toward admission into the program.

Applicant agrees this and other related information on this application may be shared with the staff of Grace Place Ministry, Inc.

By entering your name below, you are signing the document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.


It has been brought to our attention that some forms submitted to us are lost in transit or delayed getting to us. PLEASE call 615-881-3976 after you submit the form to confirm that we have received it.