Application

Application

Start your new path of life today!
Complete this brief form and an Intake Coordinator will contact you. Hope is within your reach.
Full Name:*

First NameLast Name
Age:*
Phone Number:*
Email Address*
example@example.com
Address (if no stable residence, enter city and state)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person (Name and Phone Number):*
Gender at Birth:*

MaleFemale
Marital Status:*

MarriedSingle
Forms of Valid Identification (Check All That Are in Your Possession):*

State Driver's LicenseBirth CertificateSocial Security CardPassportMarriage LicenseMilitary ID
How Did You Hear About Us?*

Internet SearchFamily/FriendChurchFacebookOther
Children (Name, Gender, and Age); Enter "none" if you do not have children.*
Any Current, Pending, or Past Charges? Please List Charges or Enter "none."*
Are You Required to Register as a Sex Offender or Arsonist?*

Sex offenderArsonistNeither
Do You Have Any Civil/Legal Lawsuits You Are Involved In?*

YesNo
Do You Have Any Pending Civil/Legal Lawsuits?*

YesNo
List any Upcoming Court Dates or Enter "none":*
Are You on Probation or Parole?*

YesNo
Is the Court Committing You to Teen Challenge? If so, please explain. *
Health Conditions (Physical/Mental). Enter "none" if no conditions:*
Current Prescription Medications?*

YesNo
Please List Your Medications or Enter "none" if not taking prescriptions.*
Where Do You Currently Live?*

Your own house/apartmentStaying with someoneHomeless
Have You Been Enrolled in Teen Challenge or a Similar Program Before? If so, list name and location.*
Have You Printed the Medical Form for You and/or Your Child (to be completed by your doctor)? See forms below.*

YesNo
Please Briefly Describe Why You Are Seeking Help.*
Medical Form - for the person enrolling

Please print form and give to your doctor to complete.

To print:
On a computer, right click and select print.
On a mobile phone, press on the icon in the upper right corner to open the form in a new window and then select print as you normally would.
Medical Form - for the person enrolling
Medical Form - for children

Please print form and give to your doctor to complete.

To print:
On a computer, right click and select print.
On a mobile phone, press on the icon in the upper right corner to open the form in a new window and then select print as you normally would.
Medical Form - for children
Should be Empty:

Application

Complete this brief form and an Intake Coordinator will contact you. Hope is within your reach.