FIND YOUR PURPOSE. PROTECT YOUR FUTURE. Application "*" indicates required fields Step 1 of 20 0% PERSONAL DATA AND INFORMATIONLast Name*First Name*MI*Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Work PhoneGender at birth*Select optionMaleFemaleWeight*Height*Hair color*Eye color*Social Security Number*Birth Date* MM slash DD slash YYYY Age*Do you have a driver's license?*Select optionYesNoDriver's License Number*State*Select optionAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDriver's License Condition*Select optionValidExpiredSuspendedIf Suspended, explain* Emergency ContactDo you have an emergency contact?*Select optionYesNoFull Name*Relationship*Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Work Phone Who has referred you to teen challenge?Did someone refer you?*YesNoFull Name*Relationship*Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Work Phone Race/Ethnic backgroundYour race/ethnic Please check only one)* American Indian or Alaska Native Asian Black or African American Latino/Hispanic Native Hawaiian or Other Pacific Islander White Other Are you a United States citizen?* Yes Native Naturalized No If no, explain* Personal Family historyList parents / parenting figures, spouse, girl/boyfriend, brothers and sisters (do not include your children) Name Age Residence Phone Actions There are no Entries. Add Entry Maximum number of entries reached. *We will attempt to communicate with family members and those listed here.How was your relationship with your parents as a child?Select optionVery GoodGoodAverageFairPoorHow is your relationship with your parents now?Select optionVery GoodGoodAverageFairPoorIs your father still living?Select optionYesNoIs your mother still living?Select optionYesNoAre you adopted?Select optionYesNoWere you raised by anyone other than your parents?Select optionYesNoIf yes, explain:When did you last see your parents?When did you last live at home?Father's OccupationMother's OccupationParent's marital statusSelect optionMarriedDivorcedSeparatedRemarriedLiving TogetherIf married, how long?If other, how long?How would you rate their marriage?Select optionVery HappyHappyAverageUnhappyGrowing up, who did you feel closest to?Select optionFatherMotherOtherIf other, who?How would you rate your childhood?Select optionGoodFairPoorWhy? MARITAL/ INTIMATE RELATIONSHIP HISTORYMartial Status*Select optionSingleMarriedCommon LawSeparatedDivorcedWidowedRemarriedList your present living arrangement (Please check all that apply)* Living alone With parents With spouse With others (non-relatives) With others (relatives, living children) Please list previous marriage(s), starting with the most recent marriage. List your former wife’s name, month and year you were married, reason the marriage ended, month and year it ended, and number of children from that marriage.Do you have any children?Select optionYesNoIf yes, please list. Name of child Age Where living Actions There are no Entries. Add Entry Maximum number of entries reached. Describe any positive or negative aspects of your relationship with your childrenDescribe any problems or concerns related to your relationship with your spouseHave you been sexually abused?*Select optionYesNoWhen and by who?*How old were you?*Were there multiple instances?*Select optionOnceSeveral timesOngoingDo you still have contact with this person?*Select optionYesNoTo your knowledge, has anyone in your family been sexually abused?*Select optionYesNoWho and by who?*Sexual lifestyle (Please check all that apply)* Bisexual Heterosexual Homosexual Pornography Prostitution Any recently involved?*Have you ever engaged in homosexual activities?*Select optionYesNoExplain* Military Services historyHave you ever served in the US Armed Forces*Select optionYesNoIf yes, describe*Branch of service*Entry date* MM slash DD slash YYYY Discharge date* MM slash DD slash YYYY Military occupation standing (MOS)*Rank attained*Discharge received*Select optionHonorableLess than honorableDishonorableEligible for VA medical benefits*Select optionYesNoUnknownIf unknown, explain* Legal HistoryAre you legally mandated to participate in a Teen Challenge type program?*Select optionYesNoIf yes, by whom?*Select optionParole BoardCourtOtherIf other, explain*If answer is "Court", please list county of origin*Are you currently or will be under legal supervision?*Select optionYesNoMethod of reporting*Select optionPhoneLetterIn PersonIf in person, explain*How often do you report?*How long?*Time remaining*Probation or Parole Officer's name*Agency*Phone Number*Address* Street Address City State / Province / Region ZIP / Postal Code Are any of the following pending again you?*Select optionYesNoAre any of the following pending against you? (Please check all that apply)* Arrest Warrant Court Appearance Criminal Charges Sentencing Other List all arrests and convictions Date Charges Conviction Sentence Time in jail Drug related? Actions There are no Entries. Add Entry Maximum number of entries reached. Have you ever been in prison?*Select optionYesNoIf yes, provide info below Date Institution Actions There are no Entries. Add Entry Maximum number of entries reached. Financial StatusDo you have someone who will be financially responsible for you?*Select optionYesNoMedical*Dental*Are you eligible for and/or receiving public assistance?*Select optionYesNoWhat kind of assistance?*Select optionWelfareDisability paymentsUnemployment compensationWorkman's CompensationOtherIf other, explain*Have you ever applied for food stamps?*Select optionYesNoWhere?*Do you have any outstanding debts?*Select optionYesNoExplain below Owed to Amount Address Phone Payment Actions There are no Entries. Add Entry Maximum number of entries reached. Significant Life EventsHave you ever experienced the following:* Moves Losses (personal, financial) Physical abuse/neglect Foster home placement or institutionalization Ethnic/cultural influences None of the following Describe your experience with moves*Describe your losses (personal, financial)*Describe your experience with physical abuse/neglect*Describe your experience with foster placement or institutionalization*Describe your experience with ethnic/cultural influences* Academic HistoryList the highest grade you completed*Are you currently in an educational program?*Select optionYesNoIf yes, name of school*City of School*If you are no longer in an education program, please explain your reason for leaving school*Are you receiving or have you received vocational training?*Select optionYesNoIf yes, list Type of Trade/Skill Start Date End Date Certificate Issued Actions There are no Entries. Add Entry Maximum number of entries reached. Can you read?*Select optionYesNoGoodAveragePoorHow well?*Select optionGoodAveragePoorCan you write?*Select optionYesNoGoodAveragePoorHow well?*Select optionGoodAveragePoorDescribe your future educational goals and plans*Describe your future vocational training goals and plans* Occupational HistoryDo you have an employment history?*Select optionYesNoWhat is your vocational trade or profession, if any?*How many jobs have you held in the last two years?*List your present employment status*Select optionUnemployment (Have not sought employment in the last 30 days)Unemployment (Have sought employment in the last 30 days)Employed part-time (Working less than 35 hours per week)Employed full-time (Working 35 hours per week)List your two most recent jobs: (Start with your most recent job) Name of Employer Position held Dates Employed Reason for Leaving Actions There are no Entries. Add Entry Maximum number of entries reached. List your current average monthly income*Describe your future occupational goals and plans*Skills*Have you ever experienced or presently have a physical ailment, injury, or handicap that would prevent you from performing manual work-related tasks while you are enrolled in Teen Challenge?*Select optionYesNoIf yes, explain* Psychological HistoryHave you ever received mental health treatment?*Select optionYesNoIf yes, please list Date Name of Clinic Reason for Mental Health Treatment Outcome Actions There are no Entries. Add Entry Maximum number of entries reached. Has a family member or someone close to you ever attempted or committed suicide*Select optionYesNoHave you ever thought about committing suicide*Select optionYesNoAre you currently thinking about committing suicide?*Select optionYesNoHave you ever received psychiatric care?*Select optionYesNoIf yes, explain*Will you, as a student of Teen Challenge, be willing to authorize doctos or agencies involved in previous treatments to release your medical records?*Select optionYesNo Insurance InformationDo you have insurancre?*YesNoSelect your health insurance type*Select optionNo health insuranceMedicaid/MedicareOther private insuranceOther public fundsIf other public funds, please list*Insurance policy number*Company* Personal / Family Medical HistoryHas your family experienced any drug/alcohol abuse?*Select optionYesNoGrandparent* Drug abuse Alcoholism Physical Problems Mental Health Problems Father* Drug abuse Alcoholism Physical Problems Mental Health Problems Mother* Drug abuse Alcoholism Physical Problems Mental Health Problems Spouse* Drug abuse Alcoholism Physical Problems Mental Health Problems Brother* Drug abuse Alcoholism Physical Problems Mental Health Problems Sister* Drug abuse Alcoholism Physical Problems Mental Health Problems Child* Drug abuse Alcoholism Physical Problems Mental Health Problems Describe any illness and/or development problem or concern you experienced as a child*Did you have any illness and/or develop mental problem as a child?*Select optionYesNoDo you have any previsions or current medical conditions?*Select optionYesNoDescribe any previous and current medical conditions*Do you currently take medication?*Select optionYesNoList all medications you are currently taking*Do you have any allergies?*Select optionYesNoList your allergies below*Have you ever struggled with:Select optionAnorexiaBulimiaAbusing self (cutting)Abusing othersSexPornographyGamblingOver-eatingStealingVideo GamesWork-a-holicNone of the aboveIf yes to any, explainDo you feel that you are addicted to any kinds of foods? If yes, explainDo you use nicotine?*Select optionYesNoAmount you consume each day*Have you ever used any of the following?*Select optionYesNoAlcohol* Never Once Several Times Regularly Daily Benzos (Valium, Xanax, etc.)* Never Once Several Times Regularly Daily Amphetamines (Adderrall, Ritalin, etc.)* Never Once Several Times Regularly Daily Opiate Painkillers (Oxy, Roxy, Hydro, etc.)* Never Once Several Times Regularly Daily Heroin* Never Once Several Times Regularly Daily Methamphetamine (Ice, Glass, Gravel, etc.)* Never Once Several Times Regularly Daily MDMA (Ecstasy, Molly, etc.)* Never Once Several Times Regularly Daily Marijuana* Never Once Several Times Regularly Daily Synthetic Marijuana (Spice, K2, etc.)* Never Once Several Times Regularly Daily Hallucinogenic (Mushrooms, LSD, etc.)* Never Once Several Times Regularly Daily Methadone, Suboxone, etc.* Never Once Several Times Regularly Daily Cocaine (Crack)* Never Once Several Times Regularly Daily Cocaine (powder)* Never Once Several Times Regularly Daily Cold Medication (DXM, Triple C, etc.)* Never Once Several Times Regularly Daily PCP (Sherm, Angel Dust, etc.)* Never Once Several Times Regularly Daily Kraton* Never Once Several Times Regularly Daily IV use of any drug (please specify)* Never Once Several Times Regularly Daily Others (please specify)* Never Once Several Times Regularly Daily Do you currently have a physician?*Select optionYesNoPresent Physician's name*Phone*Address* Street Address City State / Province / Region ZIP / Postal Code Spiritual HistoryAre you born again?*Select optionYesNoDate* MM slash DD slash YYYY Place*Denominational preferences?*How often do you attend church?*Select optionNeverOccasionallyRegularlyAre you a member of any church religion?*Select optionYesNoIf yes, which church/religion?*Did you attend church as a child?*Select optionYesNoWhat denomination was it?*How old were you when you stopped attending?*Why did you stop attending?*Do you believe in God?*Select optionYesNoUncertainDo you pray?*Select optionNeverOccasionallyOftenDo you read books of other religions instead of the Bible?*Select optionNeverOccasionallyOftenWhich ones?*Have you had recent changes in your religion life?*Select optionYesNoWhat were they?*Have you ever been involved in a cult?*Select optionYesNoIf so, Explain* The ProblemWhat is your main problem, as you see it?*What have you done about it?*What are your greatest needs in order of priority?*Have you ever been in a program before?*Select optionYesNoWas it:*Select optionReligiousNon-religiousHow many programs have you been in?*Have you ever been in a Teen Challenge program?*Select optionYesNoWhen?*Where?*Why did you leave the program?*Select optionDismissed by staffLeft on your ownCompleted the programOtherIf other, what was it?*Why do you wish to be admitted?*What are you expecting (believing) God to do in your life through the program?*Describe what you are willing to do, or what you think is required of you?*What would you like to do after you leave Teen Challenge?* The undersigned student applicant fully acknowledges that the information provided herein is accurate and true to the best of his or her knowledge, and that the applicant form has been completed and filled out by student applicant in his or her own handwriting. Student applicant further understands that any false or incomplete information may cause and result in disqualification from admittance into the program. Whether a student is just entering into or is in fact in the program.Signature*Reset to re-sign.Date* MM slash DD slash YYYY If the enclosed application form has been completed or filled out by anyone other than the student applicant, please provide the following: Did someone other than the applicant complete this document?*Select optionYesNoName of the person completing and filling our application form*Relationship to applicant*Date* MM slash DD slash YYYY Explain why student applicant was unable to complete or fill our the enclosed application form* Medical ProceduresSick Call: Report to senior staff on duty You must be experiencing diarrhea, vomiting, and/or fever to be placed on bed rest If you are not, do not ask to go on bed rest Once on bed rest, You will remain down until the next morning (no naps, no getting up to attending evening activities, no phone calls or free time, etc....) Your food (soup) will be brought to you Medication Call: Report at the posted medication times bring water with you in a cup or bottle Wait for the person in front of you to leave before approaching medicine area or you are in called in Be sure Staff clearly sees what you are taking, and take your meds in front of them Initial in proper space in medication log Medication Appointment: The need must be fairly URGENT Fill our a NEEDS SLIP and put in Program Director's box If Dental appointments are no serious, you will need to wait until your pass to get them taken care of. Prescriptions will be filled as soon as possible and at your expense (a family member may pick them up for you and give them directly to staff). Have family mail them if possible.Emergencies: You will be taken to the Emergency Room at your own cost We will do our best to have a staff member present with you the entire time.Medical Leave (initialed by staff and/or Doctor only): If you break a bone or are in need of surgery If you are having medication difficulties which must be worked out over time.Student Signature*Reset to re-sign.Date* MM slash DD slash YYYY Adult & Teen Challenge Mid-America Admission Requirements No applicant will be admitted with photo identification, social security card, and a completed application. Applicants requiring detoxification must do so prior to entry. Applicants must be in good health, free of any infections at the time of entry. Medical documentation of any disabilities or medical conditions requiring medication is required to accompany application. Upon entry, applicants will be tested for the Human Immunodeficiency Virus (HIV), Tuberculosis, Syphilis, and Hepatitis. Upon entry applicants will be required to pay an induction fee of $500 Applicants are required to have read and become familiar with Student handbook By my digital signature at the bottom of this page, I understand that upon admission into Adult & Teen Challenge Mid-America: I place myself under the authority of the staff of Adult & Teen Challenge Mid-America. I do hereby acknowledge that I understand the rules and guidelines in the Student Handbook of Adult & Teen Challenge Mid-America. I understand that I will receive disciplinary action, up to and including dismissal from the program, for not following the rules and guidelines of the Student Handbook. Digital Signature*Reset to re-sign.Date* MM slash DD slash YYYY
