ATCSMC Student Application

Student Application Instructions

Important Information
IMPORTANT: We cannot accept an applicant who has been convicted of a sexual crime or is positive for HIV.

IMPORTANT: At this time we cannot accept applicants who are on mood altering, depression or anxiety medications. If you take any of these, and you would still like to enter the program, you must come off of them first with your doctor’s approval and under their supervision. We require written verification stating that this has been achieved. You may also be required to go through medical detox prior to entering due to the fact that we are not a medical facility.

IMPORTANT: You must have two valid forms of ID. One form of ID must be a driver’s license or picture ID. The other may be a S.S. card, certified copy of a birth certificate, or a passport. If you do not have two valid forms of ID we encourage you to begin the process of getting your ID now. We cannot allow you to enter the program without them. If you are unsure of how to get an ID please call us and we will help guide you through the process.

IMPORTANT: Once your entry date and time is set you must be on time! This program is structured and regimented which dictates all our time frames; if you are late, it’s possible you may have to reschedule.

Friend, you are at a crossroads in your life. In Deuteronomy 30:19 God says He sets life and death before us. He urges us to choose life but YOU must choose your path. You may not know how the next step will work out but God will provide a way if you trust Him. We are here to help in any way we can but the responsibility to follow through and get things done falls on you. The question is how bad do you truly want a changed and hopeful life?

Sincerely,

Administration

Program Requirements
• You must be 18 to 50 years of age

(Exceptions may be made for applicants over 50 years of age who have extremely good health.)

• You must have a substance abuse issue, or other life controlling problem.

• Willing to consider a Christian faith-based approach to recovery.

• Willing to commit to a minimum of 12 months.

• Willing to share a room with others of different races and backgrounds.

• Willing to cut off all contact with non-family members while in the program.
(This includes girlfriends, fiancés and friends.)

• Must have a Social Security Card and Photo ID

• Must submit to random drug tests while in the program (This includes, but is not limited to nicotine testing since we are a no nicotine facility.)

• Must submit to a full body and belongings search upon entry to the program.

• You must have no physical limitations and be able to participate in all program activities. (Classes, walking, hiking, climbing into van, lawn care, maintenance, house cleaning, work detail, etc.)

• Non-psychiatric medications prescribed by a doctor for physical issues such as epilepsy, blood pressure, diabetes, etc. are allowed and are administered by staff only.

• We do not allow any psychiatric or anti-depressant medications to be taken while in the program (This includes, but is not limited to prescription painkillers, mood stabilizers, etc.)

• Medications that are NOT allowed during the program include, but are not limited to, the following: methadone, suboxone, vivitrol, etc.

• We cannot accept those who are HIV positive.

• We cannot accept those who have been convicted of a sexual crime.

• All students entering our program will apply for government assistance (EBT) or pay an additional monthly fee of $140 for food cost.

Sign your name to establish that you have read, understand, and agree to all the above.
Signature*

Clear

Student Application
Name*

First Name Middle Name Last Name
Date of Birth*

MonthDay Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Security Number
Driver's License Number
Do you have a High School Diploma or GED?

YesNo
Last Grade Completed
Race / Ethnic Background

WhiteAfrican AmericanAsianHispanicNative AmericanOther
Please describe your current living conditions:
Who referred you to Adult & Teen Challenge of the Smokies Men's Center?
Reference Phone Number
Please enter a valid phone number.

Emergency Contacts

MUST BE IMMEDIATE FAMILY, RELATIVE, OR PASTOR OF THE APPLICANT
Emergency Contact #1

First Name Last Name
Relationship to Applicant
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact #2

First Name Last Name
Relationship to Applicant
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact #3

First Name Last Name
Relationship to Applicant
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Statement of Faith
1. We believe the Bible is the inspired, infallible, and authoritative written Word of God.

2. We believe there is one God, eternally existent in three persons: God the Father, God the Son and God the Holy Spirit.

3. We believe in the deity of our Lord Jesus Christ, His virgin birth, His sinless life, His miraculous ministry, His atoning death, in His bodily resurrection, in His Ascension to the right hand of the Father, and His personal return to earth, at which time he will judge the quick and the dead.

4. We believe the only means of being cleansed from sin is through repentance and faith in the precious blood of Jesus Christ.

5. We believe in the ordinances of the church: Holy Communion and Water Baptism.

6. We believe in the infilling of the Holy Spirit, and reliance on his power working in and through us.

7. We believe the redemptive work of Christ on the cross provides divine healing of the human body through prayer and petition according to Gods will.

8. We believe in the sanctifying power of the Holy Spirit by whose indwelling the Christian is enabled to live a life of devotion and integrity.

9. We believe in the Blessed Hope, the imminent return of Jesus Christ followed by his reign on the earth for 1,000 years.

10. We believe in the resurrection of the saved and the lost, the one to everlasting life and the other to everlasting damnation.

11. We Believe the biblical order for human sexual expression as being between one man and one woman who have committed to a life-long marriage covenant (Gen 2:24, Matt. 19:5). Any expression of human sexuality outside of the marriage covenant between one man and one woman is sin (Ex. 20:14; Lev 18:22-23,20:13; Matt 15:19). God wants us to avoid sexual immorality and live holy and honorable lives of faithfulness.
I have read this statement of faith and acknowledge that while I am not required to believe according to the Statement, I am required to attend classes and worship services where these beliefs are taught. I further agree that I will not engage in religious debate or disrespectfully criticize my teachers or the beliefs that they teach. I understand that the teachers will be teaching their interpretation according to this Statement of Faith.
Signature*

Clear
Today's Date*

MonthDay Year
Date

Student Agreement
1. I have read the general program rules for Adult and Teen Challenge of the Smokies Men’s Center (ATCSMC) and consent to abide by all of them, whether I agree with them or not.

2. I will dedicate myself to the discipleship program until it is recognized by the ATCSMC staff that I qualify for completion; I should come to realize that I cannot do this in my own strength.

3. I release to ATCSMC the right to search, read, and withhold my mail in the manner explained in the rules.

4. I release the right to ATCSMC to do a room search and/or drug screen whenever they deem it necessary.

5. I release the right to ATCSMC to make a thorough search of my person and belongings on the day of my admission.

6. I understand that ATCSMC will not be held responsible for any of my personal property left, lost, or stolen while I am in the ATCSMC program. When leaving ATCSMC, I understand that all my personal property must be taken with me.

7. I release ATCSMC from all financial or legal responsibilities in case of accident, injury, illness, any possible medical or dental issues or other misfortune.

8. I understand that I will be required to do various work projects while in the program (physical labor). I will not receive payment for the work I do while in the ATCSMC program. I also understand that the purpose of this work is to aid in my vocational training.

9. I release the right to ATCSMC to withhold any of my belongings that they deem necessary; any items not allowed according to the guidelines will be sent home, possibly discarded, or held for me until my departure.

10. I understand that upon arrival I must deposit with ATCSMC the cost of return taxi fare and bus ticket to be held for me in case I am dismissed or decide to leave the ATCSMC program prematurely.

11. I agree to submit to the authority of all staff members who may direct me while I’m a student of ATCSMC.
Signature*

Clear
Today's Date*

MonthDay Year
Date

General Program Rules
The following are some of the basic rules at ATCSMC.

A complete guidelines handbook will be provided upon entrance.
Christian Discipleship and Training Center:

1. I understand that ATCSMC is a Christian discipleship and training program and I agree to be subject to Biblical teaching and Christian forms of behavior.

2. I agree to always assume personal responsibility for my own attitude and behavior. I understand that what program authority calls incorrect behavior, and a bad attitude will be confronted and may be disciplined if necessary. I will agree to do the disciplinary action or project with a willing attitude.

3. I understand that my main purpose for being in the program is to learn a new way of life according to biblical standards, not just to get off drugs and/or get out of jail.

Personal:

1. I will not possess or use drugs at any time, including psychiatric medication.

2. I will not possess or use any tobacco product; this includes the vapor type smoking devices.

3. I will not curse or use off-color expressions or bodily gestures.

4. I will not talk about street life, drugs, sex, partying or reminisce about past sinful practices.

5. I will not horseplay or engage in any other inappropriate body contact.

6. I will not become part of a limited social group that excludes others.

7. I will not call other people names- including nick names that may connect them to their past life.

8. I will not go outside of the men’s dorm without staff permission.

9. I will not bring a radio, tape/CD device, phone, iPod, musical instruments, books, knives, lighters, etc.

Family:

1. I understand that I will be allowed to write letters to immediate family members, relatives, and pastor starting the day I enter the program. I consent to ATCSMC staff screening and reading all incoming and out-going mail.

2. I agree to only contact members of my immediate family, relatives, and pastor through approved contact methods – there will be no contact with girlfriends, fiancés, or friends. Approved contact methods include letter writing, phone calls, visits and passes.

3. I agree to make only two 10-minute phone calls per week, after a 21-day waiting period.

4. I agree to not have any visits until after 40 days.

Group:
1. I agree to participate in all scheduled activities including class, chapel, choir, church, work, and recreation. I will participate in each of these activities.

2. I agree to conduct myself in a reserved, polite manner and will not do anything in public that will call negative attention to myself or reflect badly upon the whole group.

3. I understand the length of the ATCSMC Program is a minimum of 12 months. I agree to commit to complete phases 1-4 of the ATCSMC Program.

Discipline:

1. I understand that I am to be prepared, in place, and arrive on time for all scheduled activities. I also understand that tardiness, unpreparedness, or any other form of carelessness will result in disciplinary action.

2. I understand that my room must be kept in a neat and orderly manner. I agree to cooperate with my roommates to keep it clean and orderly for daily inspection.

3. I understand there is a dress code.

4. I understand there are grooming and hygiene requirements which include, but are not limited to the following: shaving, brushing of teeth before 1st period, combing of hair (also before 1st period and throughout the day), hair length, hair style, daily shower, etc.

5. I understand that disciplinary action may include extra duties, loss of privileges, suspension, or dismissal.
By signing below, I am indicating that I have a good understanding of these rules, and that I am willing to commit myself to this agreement. I also understand that I will receive a more detailed Handbook Agreement during intake.
Signature*

Clear
Today's Date*

MonthDay Year
Date

Release of Information
VERY IMPORTANT: This release of Information document informs us of any person that you want informed of your intent to enter the program, or who may be involved in your intake process. The information exchanged with these people may be utilized to determine your eligibility for the program and develop or revise a treatment plan once enrolled.

Due to federal confidentiality laws, you must list EVERY person (including immediate family members) that we may communicate with during your intake process.
Client (Applicant) Name*

First Name Middle Name Last Name
I hereby give Adult and Teen Challenge of the Smokies Men’s Center permission to communicate with the persons/entities listed below on my behalf for the purpose of determining my eligibility for, and/or facilitating my entry into, the ATCSMC residential addiction recovery program located in Franklin, NC.
Person/Entity #1

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship to you
Person/Entity #2

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship to you
Person/Entity #3

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship to you
Client (Applicant) Signature*

Clear
Today's Date*

MonthDay Year
Date
This consent is subject to revocation in writing by the student at any time except to the extent that the ministry or person who is to make the disclosure has already acted on it. This consent automatically expires one year and six months from the date it is signed.

Consent for the Release of Information
Name*

First Name Middle Name Last Name
Date of Birth*

MonthDay Year
I hereby authorize and request:

          Adult & Teen Challenge of the Smokies Men’s Center

to obtain/release information regarding my medical, psychological, legal, or financial situation from/to any entity which has participated in my care and/or legal matters.

1)   I understand that such disclosures will be made for the following purpose: medical, psychological, legal and financial.

2)   I understand that my records are protected under Federal Confidentiality Regulations and cannot be disclosed without consent unless otherwise provided for in the regulations.

3)   I understand that I may revoke this consent at any time except to the extent that action has already been taken based on this authorization.

4) I understand that unless I submit a written revocation at an earlier date, this authorization will expire 30 days after discharge from the program.
Today's Date*

MonthDay Year
Date
Signature*

Clear

Statement of Student Rights
1. You will be fully informed upon admission of your rights and responsibilities and limitations of those rights imposed by the agreements of Adult and Teen Challenge of the Smokies Men’s Center (ATCSMC).

2. You may voice grievances to: 1) First, your counselor or staff, 2) to the Program Director and then 3) the Executive Director of ATCSMC and to outside representatives of your choice with freedom from restraint, interference, coercion, discrimination, or reprisal.

3. You will be treated with consideration, respect, and full recognition of your dignity and individuality.

4. You will be protected by your leaders at ATCSMC from neglect from physical, verbal and emotional abuse (including corporal punishment) and from all forms of exploitation.

5. ATCSMC will assist you in the exercise of your civil rights.

6. You will not be expected to perform services which are ordinarily performed by the staff of ATCSMC.

7. Upon admission you will be allowed to fill out a mailing list of family members with whom you desire to communicate, subject to approval by your assigned Life-Coach and the Program Director. Mail will be opened in the administration office and given to your Life-Coach for delivery to the student. Packages received will be opened in the presence of the staff. However, any mail or other communication which is not delivered to the student for whom it is intended shall be returned to the sender.

8. You will participate in the development of the “Life-Map” for your growth while here at ATCSMC. You will also receive sufficient information about proposed and alternative interventions and program goals.

9. You will participate in all scheduled activities including class, chapel, choir, church, work, and recreation.

10. You will have free use of designated areas in the facility. Consideration will be given regarding privacy, personal possessions, and the rights of others.

11. You will be provided privacy for the use of the bathrooms and showers.

12. Your personal items are subject to approval by the guidelines of ATCSMC.

13. You will be allowed visits at designated times and places under supervision.

14. Should you feel the need of outside assistance, you have the right to call the appropriate advocacy representative. Some are listed below:

-       Health Department

-       American Civil Liberties Union

-       Macon County Sheriff's Department

Title VI of the 1964 Civil Rights Act

“No person in the United States shall on the basis of race, color or national origin, be excluded from participation in, be denied benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”

Prohibited Practices:

· Denying any individual services, opportunities, or other benefits for which that individual is otherwise qualified;

· Providing any service or benefit in a different manner from that which is provided to others in a program because of race, color, or national origin;

· Segregating service recipients solely because of race, color, or national origin;

· Restricting access to program services or benefits because of race, color, or national origin;

· Adopting methods of administration which would limit participation by any group of recipients or subject them to discrimination;

· Addressing an individual in a manner that denotes inferiority because of race, color, or national origin.
Should be Empty:

Student Application Instructions

Important Information

Program Requirements

Student Application

Emergency Contacts

Personal Information

Statement of Faith

Student Agreement

General Program Rules

Release of Information

Consent for the Release of Information

Statement of Student Rights