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.
EMAIL ADDRESS*
example@example.com
GENDER*

MALEFEMALENON BINARY
SELECT CENTRE YOU WOULD LIKE TO APPLY TO*

WINNIPEG MENTHUNDER BAY MENTHUNDER BAY WOMANBRANDON WOMANSTEINBACH MENFLIN FLON MEN
DATE OF BIRTH*

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

SINGLEMARRIEDCOMMON-LAWSEPERATEDDIVORCED
NAME OF SPOUSE*

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

YESNO
WHAT IS THE GENERAL CONDITION OF YOUR HEALTH?*
DO YOU HAVE A HEALTH CARD OR HEALTH INSURANCE?*

YESNO
PLEASE INPUT YOUR HEALTH CARD NUMBER*
HAVE YOU EVER BEEN TREATED FOR AIDS?*

YESNO
HAVE YOU RECENTLY TESTED POSITIVE FOR ANY COMMUNICABLE DISEASES?*

YESNO
ARE YOU SEEING A MEDICAL DOCTOR FOR ANY REASON?*

YESNO
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.
ARE YOU CURRENTLY TAKING ANY PRESCRIPTION MEDICATIONS?*

YESNO
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?*

YESNO
PLEASE GIVE US MORE DETAILS:*
DO YOU REQUIRE A DOCTOR PRESCRIBED DIET?*

YESNO
DO YOU HAVE ANY ALLERGIES?*

YESNO
PLEASE GIVE US MORE DETAILS:*
DO YOU HAVE HIGH BLOOD PRESSURE?*

YESNO
PLEASE GIVE US MORE DETAILS:*
DO YOU HAVE CANCER?*

YESNO
PLEASE GIVE US MORE DETAILS:*
DO YOU HAVE ASTHMA?*

YESNO
PLEASE GIVE US MORE DETAILS:*
DO YOU HAVE DIABETES?*

YESNO
PLEASE GIVE US MORE DETAILS:*
DO YOU HAVE ANY HEART PROBLEMS?*

YESNO
PLEASE GIVE US MORE DETAILS:*
DO YOU HAVE EPILEPSY?*

YESNO
PLEASE GIVE US MORE DETAILS:*
HAVE YOU EVER, OR ARE YOU NOW RECEIVING PSYCHIATRIC TREATMENT?*

YESNO
PLEASE GIVE US MORE DETAILS:*
HAVE YOU EVER BEEN CONVICTED OF ANY CRIMES?*

YESNO
PLEASE GIVE US MORE DETAILS:*
ARE YOU CURRENTLY IN JAIL?*

YESNO
PLEASE GIVE US MORE DETAILS ABOUT RELEASE DATE AND THE NAME OF INSTITUTION:*
ARE YOU ON PROBATION OR PAROLE?*

YESNO
PROBATION/PAROLE OFFICER'S NAME*

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

Street Address

Street Address Line 2

CityState / Province

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

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

Street Address

Street Address Line 2

CityState / Province

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

YESNO
NEXT UPCOMING COURT APPEARANCE*

YearMonthDay
Date
Hour MinutesAM/PM Option
ARE YOU AWARE OF ANY WARRANTS FOR YOUR ARREST IN ANY PROVINCE OF CANADA?*

YESNO
ARE YOU ON A DISABILITY PENSION OR OTHER PENSION CURRENTLY?*

YESNO
PLEASE GIVE DETAILS:*
HOW MUCH MONEY DO YOU COLLECT? HOW OFTEN DO YOU COLLECT?
DO YOU HAVE OUTSTANDING DEBTS OR FINES?*

YESNO
PLEASE GIVE DETAILS:*
HOW DO YOU PLAN TO PAY THIS OFF?
ARE THERE ANY OTHER FINANCIAL MATTERS WE SHOULD BE MADE AWARE OF?*

YESNO
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 LIVE-IN PROGRAM?*

YESNO
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?*

YESNO
PLEASE STATE WHICH ATCCC PROGRAM AND HOW LONG YOU RESIDED THERE?*
DO YOU FLUENTLY READ, WRITE AND SPEAK ENGLISH?*

YESNO
PLEASE EXPLAIN:*
STATE LAST GRADE/POST SECONDARY SCHOOL/TRAINING COMPLETED*
HAVE YOU READ THE PROGRAM MANUAL IN ITS ENTIRETY?*

YESNO
DO YOU UNDERSTAND THAT THE PROGRAM IS TWELVE (12) MONTHS MINIMUM?*

YESNO
ARE YOU WILLING TO OBEY THE RULES IN THEIR ENTIRETY?*

YESNO
PLEASE COMMENT ON HOW YOU FEEL ABOUT OUR RULES:*
DO YOU SMOKE?*

YESNO
DO YOU UNDERSTAND THAT OUR APPROACH IS COLD TURKEY?*

YESNO
DO YOU CONSIDER YOURSELF TO BE AN ADDICT?*

YESNO
WHAT IS IT THAT YOU STRUGGLE WITH SPECIFICALLY?*
Signature*

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