LHOP internship - The Potters House
Please fill out this form and click submit.
Name
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Email
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This address will receive a confirmation email
Phone
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Address
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Age
*
How much time do you spend with the Lord regularly/letting Him disciple you through communion?
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Have you been born again(receiving Jesus as your Lord)?
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Do you struggle with addiction of any kind? Food, phone, movie & tv, etc.
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Do you watch porn?
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Have you been diagnosed with any disorder?
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Are you on any medication?
*
Explain family background
*
Payment(will go to tuition)
$35
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
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AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Submit
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