SURGE Online Application Form
The Phase Manager should fill out this application with the help of the applicant. You may click the 'Save' button found on the bottom of this form to save your work at any time. You will receive an email with instructions and a link to this form. For more information about the question found on this form, please reach out to the SURGE director. !IMPORTANT! This form includes an Approval Workflow. Please wait for your response email after your complete and submit your entry before taking further action.
SECTION A | Staff Information
A10. Staff Email
*
Do NOT enter the SURGE applicant's email. This form does not accept private email addresses.
A11. Region
Please Select
Winnipeg, MB
Brandon, MB
Thunder Bay, ON (MEN)
Thunder Bay, ON (WOMEN)
British Columbia
Steinbach, MB
Flin Flon, SK
Select the region that this application refers to.
A12. Date
-
Month
-
Day
Year
Date the application form is being filled out for the first time.
SECTION B | Personal Information
B10. Name
First Name
Last Name
B11. Address (center address if currently residing in the program)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
B12. Home Phone Number
Please enter a valid phone number.
B13. Work Phone Number
Please enter a valid phone number.
B14. Email Address
Applicant's email address.
B15. Birth Date
-
Month
-
Day
Year
Date
B16. Age
B17. SIN #
Please enter a valid social insurance number
B18. Driver's Licence Number
B19. Driver's Licence Province
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
B19.1 Upload valid driver's licence
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B20. Do you have valid photo ID?
Please Select
Yes
No
B20.1 Please upload valid photo ID
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B21. Do you have valid passport?
Please Select
Yes
No
B22. Adult & Teen Challenge of Central Canada Graduation Date
-
Month
-
Day
Year
Enter the date when you graduated the 4 Tier Program
B23. How long have you been drug & alcohol free?
B24. Marital Status
Please Select
Married
Separated
Remarried
Divorced
Widowed
Single
B25. Spouse Name
First Name
Last Name
B26. Spouse Occupation
B27. Number of Children
B28. List any hobbies, interests, skills and abilities
B29. Select the courses you have completed
Experiencing God
Discover Your God-Given Gifts
Knowing How To Manage Money God's Way
B30. Please explain why you haven't completed the prerequisite courses
B31. List your top 3 God-Given Gifts in order
B32. What are your 3 top Character Qualities you need to strengthen?
SECTION C | Behavioural History
C10. Is there a current criminal record or criminal record check (it must state "negative" on file in the applicant's digital folder?
Please Select
Yes
No
This question is for the Phase Manager specifically
C11. Please explain why not
All applicants must have updated legal records uploaded on their Client Folders.
C12. Are you currently on probation?
Please Select
Yes
No
C13. Please explain the conditions of your probation and when your probation will be over
C14. Name of Probation Officer
First Name
Last Name
C15. Phone Number
Please enter a valid phone number.
C16. Email
example@example.com
C17. Please Indicate Previous Addictions
C18. Please upload existing Criminal Record
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This can be found in the client's digital file on Google.
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SECTION D | Educational Information
D10. List all high schools and colleges attended beginning with the most recent
SECTION E | Employment History
E10. Last Employer
E11. Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E12. Immediate Supervisor
E13. Phone Number
Please enter a valid phone number.
E14. Date Started
-
Month
-
Day
Year
Date
E15. Date Left
-
Month
-
Day
Year
Date
E16. Please Upload a Copy of Your Resume & a Letter of Recommendation from the Program Director
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SECTION F | Religious Information
F10. Have You Accepted Christ As Your Personal Saviour and Lord?
Yes
No
F11. Date of Salvation
-
Month
-
Day
Year
Date
F12. Where?
F13. Name of Home Church
F14. Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
F15. Phone Number
Please enter a valid phone number for the church
F16. Pastor
F17. Phone Number
Please enter a valid phone number for the pastor.
F18. Denomination
F19. When and How Did Jesus Become Your Personal Saviour?
F20. How Are You Currently Cultivating Your Spiritual Life and Seeking To Mature in Christ?
F21. Why Do You Desire To Become a Student in the SURGE Program?
F22. Do You Feel God Is Calling or Has Called You to Ministry in Adult & Teen Challenge or Another Similar Ministry? Please Explain.
F23. State Any Other Aspects of Your Personal Testimony That Would Be Significant to You Becoming a Part of the SURGE Program.
SECTION G | References
Please List the Names and Addresses of Your References for a Recommendation.
G10. Name
First Name
Last Name
G11. Phone Number
Please enter a valid phone number.
G12. Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
G13. Relationship
G14. Name
First Name
Last Name
G15. Phone Number
Please enter a valid phone number.
G16. Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
G17. Relationship
G18.1. Applicant Signature
G19. Date
-
Month
-
Day
Year
Date
G20. Please Upload a Picture of Yourself
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Please ensure the photo is JPG or PNG format!
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G21. Please Upload Exit Plan
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H1.1 Supervisor Questions & Comments
H1.2 How is your applicant with Critical Thinking Skills?
H1.3 What are the areas of strengths of your applicant?
H1.4 What are the areas of weakness of your applicant?
H1.5 Can you see them being employed with ATCCC in the next 3-5 years?
H1.6 Additional Comments
Where will they be serving is the Program Director in support of this applicant?
Last Question!
*
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