Adult & Teen Challenge Certification of Affiliation
Fill out the form below to complete your center's Certificate of Affiliation
Current Day
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Current Month
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Current Year
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Legal Name of Center/Corporation
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City, State
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Phases (Check All That Apply)
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1 (Outreach)
2 (Crisis)
3 (Induction)
4 (Training)
5 (Restoration)
6 (Re-entry)
Corporate Office
Residential or Non-Residential
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Residential
Non-residential
Population Served
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Men (aged 18+)
Women (aged 18+)
Adolescent Boys (under 18)
Adolescent Girls (under 18)
Women with Children
Families
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Signature of CEO
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Name of CEO
*
Title of CEO
*
CEO Email
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