LIVE-IN PROGRAM APPLICATION

LIVE-IN PROGRAM APPLICATION

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

First NameMiddle NameLast Name
CURRENT ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
CONTACT PHONE NUMBER
Please enter a valid phone number.Format: 0 (000) 000-0000.
EMAIL ADDRESS
example@example.com
GENDER
SELECT CENTRE YOU WOULD LIKE TO APPLY TO
DATE OF BIRTH

YearMonthDay
Date
SOCIAL INSURANCE NUMBER
Please enter a valid SIN #Format: 000-000-000.
HOW DID YOU HEAR ABOUT ATCCC? PLEASE GIVE NAME OF INDIVIDUALS, AGENCIES OR GROUPS:
EMERGENCY CONTACT

First NameLast Name
EMERGENCY CONTACT PHONE NUMBER
Please enter a valid phone number.Format: 0 (000) 000-0000.
THEIR RELATIONSHIP TO YOU:
MARITAL STATUS
NAME OF SPOUSE

First NameLast Name
SPOUSE PHONE NUMBER
Please enter a valid phone number.Format: 0 (000) 000-0000.
NUMBER OF CHILDREN TOGETHER
DOES YOUR SPOUSE SUPPORT YOU COMING INTO THE PROGRAM?
WHAT IS THE GENERAL CONDITION OF YOUR HEALTH?
DO YOU HAVE A HEALTH CARD OR HEALTH INSURANCE?
PLEASE INPUT YOUR HEALTH CARD NUMBER
HAVE YOU EVER BEEN TREATED FOR AIDS?
HAVE YOU RECENTLY TESTED POSITIVE FOR ANY COMMUNICABLE DISEASES?
ARE YOU SEEING A MEDICAL DOCTOR FOR ANY REASON?
PLEASE GIVE A REASON FOR SEEING A MEDICAL DOCTOR:
NAME OF PHYSICIAN

First NameLast Name
PHYSICIAN'S OFFICE ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
PHYSICIAN'S CONTACT PHONE NUMBER
Please enter a valid phone number.Format: 0 (000) 000-0000.
ARE YOU CURRENTLY TAKING ANY PRESCRIPTION MEDICATIONS?
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?
PLEASE GIVE US MORE DETAILS:
DO YOU REQUIRE A DOCTOR PRESCRIBED DIET?
DO YOU HAVE ANY ALLERGIES?
PLEASE GIVE US MORE DETAILS:
DO YOU HAVE HIGH BLOOD PRESSURE?
PLEASE GIVE US MORE DETAILS:
DO YOU HAVE CANCER?
PLEASE GIVE US MORE DETAILS:
DO YOU HAVE ASTHMA?
PLEASE GIVE US MORE DETAILS:
DO YOU HAVE DIABETES?
PLEASE GIVE US MORE DETAILS:
DO YOU HAVE ANY HEART PROBLEMS?
PLEASE GIVE US MORE DETAILS:
DO YOU HAVE EPILEPSY?
PLEASE GIVE US MORE DETAILS:
HAVE YOU EVER, OR ARE YOU NOW RECEIVING PSYCHIATRIC TREATMENT?
PLEASE GIVE US MORE DETAILS:
HAVE YOU EVER BEEN CONVICTED OF ANY CRIMES?
PLEASE GIVE US MORE DETAILS:
DO YOU HAVE ANY CURRENT CHARGES?
PLEASE DESCRIBE CURRENT CHARGES
COURT DATE & TIME

MonthDayYear
Date
Hour MinutesAM/PM Option
LAWYERS NAME

First NameLast Name
LAWYERS PHONE NUMBER
Please enter a valid phone number.Format: 0 (000) 000-0000.
LAWYERS OFFICE ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
ARE YOU CURRENTLY IN JAIL?
PLEASE GIVE US MORE DETAILS ABOUT RELEASE DATE AND THE NAME OF INSTITUTION:
ARE YOU ON PROBATION OR PAROLE?
PROBATION/PAROLE OFFICER'S NAME

First NameLast Name
PROBATION/PAROLE OFFICER'S PHONE NUMBER
Please enter a valid phone number.Format: 0 (000) 000-0000.
PROBATION/PAROLE OFFICE ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
PLEASE GIVE US DETAILS ABOUT REPORTING METHODS:
DO YOU HAVE ANY UPCOMING COURT APPEARANCES?
NEXT UPCOMING COURT APPEARANCE

YearMonthDay
Date
Hour MinutesAM/PM Option
ARE YOU AWARE OF ANY WARRANTS FOR YOUR ARREST IN ANY PROVINCE OF CANADA?
ARE YOU ON A DISABILITY PENSION OR OTHER PENSION CURRENTLY?
PLEASE GIVE DETAILS:
HOW MUCH MONEY DO YOU COLLECT? HOW OFTEN DO YOU COLLECT?
DO YOU HAVE OUTSTANDING DEBTS OR FINES?
PLEASE GIVE DETAILS:
HOW DO YOU PLAN TO PAY THIS OFF?
ARE THERE ANY OTHER FINANCIAL MATTERS WE SHOULD BE MADE AWARE OF?
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 IN-RESIDENCE PROGRAM?
WHY DO YOU WISH TO ENTER INTO THIS PROGRAM?
WHAT IS YOUR RELIGIOUS PREFERENCE OR DENOMINATION?
HAVE YOU EVER BEEN TO ANOTHER ATCCC LIVE-IN PROGRAM BEFORE?
PLEASE STATE WHICH ATCCC PROGRAM AND HOW LONG YOU RESIDED THERE?
DO YOU FLUENTLY READ, WRITE AND SPEAK ENGLISH?
PLEASE EXPLAIN:
STATE LAST GRADE/POST SECONDARY SCHOOL/TRAINING COMPLETED
HAVE YOU READ THE PROGRAM MANUAL IN ITS ENTIRETY?
DO YOU UNDERSTAND THAT THE PROGRAM IS TWELVE (12) MONTHS MINIMUM?
ARE YOU WILLING TO OBEY THE RULES IN THEIR ENTIRETY?
PLEASE COMMENT ON HOW YOU FEEL ABOUT OUR RULES:
DO YOU SMOKE?
DO YOU UNDERSTAND THAT OUR APPROACH IS COLD TURKEY?
DO YOU CONSIDER YOURSELF TO BE AN ADDICT?
WHAT IS IT THAT YOU STRUGGLE WITH SPECIFICALLY?
Signature
Should be Empty: