RESIDENTIAL PROGRAM APPLICATION

RESIDENTIAL PROGRAM APPLICATION

THIS APPLICATION FORM MUST BE FILLED OUT AND SIGNED BY THE APPLICANT ONLY. IF YOU DO NOT KNOW THE ANSWER PLEASE PUT "N/A" (NOT APPLICABLE).
YOUR FULL NAME *

First Name Middle Name Last Name
CURRENT ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
CONTACT PHONE NUMBER *
Please enter a valid phone number.
EMAIL ADDRESS *
example@example.com
GENDER *

MALE FEMALE NON BINARY
SELECT CENTRE YOU WOULD LIKE TO APPLY TO *

WINNIPEG MENS THUNDER BAY MENS THUNDER BAY WOMANS BRANDON WOMANS
DATE OF BIRTH *

Year Month Day
Date
SOCIAL INSURANCE NUMBER
Please enter a valid SIN #
HOW DID YOU HEAR ABOUT ATCCC? PLEASE GIVE NAME OF INDIVIDUALS, AGENCIES OR GROUPS: *
EMERGENCY CONTACT *

First Name Last Name
EMERGENCY CONTACT PHONE NUMBER *
Please enter a valid phone number.
THEIR RELATIONSHIP TO YOU: *
MARITAL STATUS *

SINGLE MARRIED COMMON-LAW SEPERATED DIVORCED
NAME OF SPOUSE *

First Name Last Name
SPOUSE PHONE NUMBER *
Please enter a valid phone number.
NUMBER OF CHILDREN TOGETHER *
DOES YOUR SPOUSE SUPPORT YOU COMING INTO THE PROGRAM? *

YES NO
WHAT IS THE GENERAL CONDITION OF YOUR HEALTH? *
DO YOU HAVE A HEALTH CARD OR HEALTH INSURANCE? *

YES NO
PLEASE INPUT YOUR HEALTH CARD NUMBER *
HAVE YOU EVER BEEN TREATED FOR AIDS? *

YES NO
HAVE YOU RECENTLY TESTED POSITIVE FOR ANY COMMUNICABLE DISEASES? *

YES NO
ARE YOU SEEING A MEDICAL DOCTOR FOR ANY REASON? *

YES NO
PLEASE GIVE A REASON FOR SEEING A MEDICAL DOCTOR: *
NAME OF PHYSICIAN *

First Name Last Name
PHYSICIAN'S OFFICE ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
PHYSICIAN'S CONTACT PHONE NUMBER *
Please enter a valid phone number.
ARE YOU CURRENTLY TAKING ANY PRESCRIPTION MEDICATIONS? *

YES NO
PLEASE GIVE US MORE DETAILS: *
HOW LONG HAVE YOU BEEN TAKING MEDICATION FOR? HOW DO YOU PLAN TO PAY FOR YOUR MEDICATION WHILE YOU ARE IN OUR PROGRAM? WHY DO YOU TAKE THIS MEDICATION?
DO YOU HAVE ANY PHYSICAL LIMITATIONS THAT WOULD HINDER YOU FROM DOING NORMAL MANUAL LABOUR? *

YES NO
PLEASE GIVE US MORE DETAILS: *
DO YOU REQUIRE A DOCTOR PRESCRIBED DIET? *

YES NO
DO YOU HAVE ANY ALLERGIES? *

YES NO
PLEASE GIVE US MORE DETAILS: *
DO YOU HAVE HIGH BLOOD PRESSURE? *

YES NO
PLEASE GIVE US MORE DETAILS: *
DO YOU HAVE CANCER? *

YES NO
PLEASE GIVE US MORE DETAILS: *
DO YOU HAVE ASTHMA? *

YES NO
PLEASE GIVE US MORE DETAILS: *
DO YOU HAVE DIABETES? *

YES NO
PLEASE GIVE US MORE DETAILS: *
DO YOU HAVE ANY HEART PROBLEMS? *

YES NO
PLEASE GIVE US MORE DETAILS: *
DO YOU HAVE EPILEPSY? *

YES NO
PLEASE GIVE US MORE DETAILS: *
HAVE YOU EVER, OR ARE YOU NOW RECEIVING PSYCHIATRIC TREATMENT? *

YES NO
PLEASE GIVE US MORE DETAILS: *
HAVE YOU EVER BEEN CONVICTED OF ANY CRIMES? *

YES NO
PLEASE GIVE US MORE DETAILS: *
ARE YOU CURRENTLY IN JAIL? *

YES NO
PLEASE GIVE US MORE DETAILS ABOUT RELEASE DATE AND THE NAME OF INSTITUTION: *
ARE YOU ON PROBATION OR PAROLE? *

YES NO
PROBATION/PAROLE OFFICER'S NAME *

First Name Last Name
PROBATION/PAROLE OFFICER'S PHONE NUMBER *
Please enter a valid phone number.
PROBATION/PAROLE OFFICE ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
PLEASE GIVE US DETAILS ABOUT REPORTING METHODS: *
LAWYERS NAME *

First Name Last Name
LAWYERS PHONE NUMBER *
Please enter a valid phone number.
LAWYERS OFFICE ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
DO YOU HAVE ANY UPCOMING COURT APPEARANCES? *

YES NO
NEXT UPCOMING COURT APPEARANCE *

Year Month Day
Date
Hour Minutes AM/PM Option
ARE YOU AWARE OF ANY WARRANTS FOR YOUR ARREST IN ANY PROVINCE OF CANADA? *

YES NO
ARE YOU ON A DISABILITY PENSION OR OTHER PENSION CURRENTLY? *

YES NO
PLEASE GIVE DETAILS: *
HOW MUCH MONEY DO YOU COLLECT? HOW OFTEN DO YOU COLLECT?
DO YOU HAVE OUTSTANDING DEBTS OR FINES? *

YES NO
PLEASE GIVE DETAILS: *
HOW DO YOU PLAN TO PAY THIS OFF?
ARE THERE ANY OTHER FINANCIAL MATTERS WE SHOULD BE MADE AWARE OF? *

YES NO
PLEASE GIVE DETAILS: *
ARE YOU SELLING A HOUSE, CAR OR ANY INVOLVED WITH ANY CIVIL LEGAL ACTIONS REGARDING CLAIMS?
DO YOU UNDERSTAND THAT ATCCC IS A CHRISTIAN DISCIPLESHIP PROGRAM AND THAT THERE ARE NO ALTERNATIVE RECOVERY TRACKS WITHIN OUR LONG TERM RESIDENTIAL PROGRAM? *

YES NO
WHY DO YOU WISH TO ENTER INTO THIS PROGRAM? *
WHAT IS YOUR RELIGIOUS PREFERENCE OR DENOMINATION? *
HAVE YOU EVER BEEN TO ANOTHER ATCCC RESIDENTIAL PROGRAM BEFORE? *

YES NO
PLEASE STATE WHICH ATCCC PROGRAM AND HOW LONG YOU RESIDED THERE? *
DO YOU FLUENTLY READ, WRITE AND SPEAK ENGLISH? *

YES NO
PLEASE EXPLAIN: *
STATE LAST GRADE/POST SECONDARY SCHOOL/TRAINING COMPLETED *
HAVE YOU READ THE PROGRAM MANUAL IN ITS ENTIRETY? *

YES NO
DO YOU UNDERSTAND THAT THE PROGRAM IS TWELVE (12) MONTHS MINIMUM? *

YES NO
ARE YOU WILLING TO OBEY THE RULES IN THEIR ENTIRETY? *

YES NO
PLEASE COMMENT ON HOW YOU FEEL ABOUT OUR RULES: *
DO YOU SMOKE? *

YES NO
DO YOU UNDERSTAND THAT OUR APPROACH IS COLD TURKEY? *

YES NO
DO YOU CONSIDER YOURSELF TO BE AN ADDICT? *

YES NO
WHAT IS IT THAT YOU STRUGGLE WITH SPECIFICALLY? *
Signature *

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