Student Application

Bethesda Transformation Center (BTC) is a faith ministry that depends solely on donations.
BTC is a Christian transformation center designed to help women who are truly ready to make a change in their life. Victory in living through Jesus Christ and the truth of the Bible is taught here. This is accomplished through classroom teaching, audio & video tapes, one-on-one counseling, homework assignments, worship services and work projects.

I have read the statements concerning the process BTC utilizes to help me and I am willing to submit to the policies BTC has in place as they help me overcome my addictions.

By Signing below I attest I am in agreement with the statement above.

Have you ever been to BTC before?

YesNo

Full Legal Name

First NameLast Name

Date of Birth

Date

Age

Phone Number

Please enter a valid phone number.

Email

example@example.com

Current Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have a High School Diploma/GED?

YesNo

Personal Reference (Give a name and number of a personal reference we may contact)

First NameLast Name

Reference Phone Number

Please enter a valid phone number.

Please explain briefly why you want to come to Bethesda Transformation Center?

When was your last drink/drug?

Date

What was it?

What drugs have you used in the past year?

Have you used IV Drugs?

YesNo

Have you used Alcohol?

YesNo

Are you subject to DT's or seizures?

YesNo

If yes, when was your last episode?

Date

NOTE:(Must be detoxed at least 5-7 days) If you come in requiring detox, you will be asked to leave and return after detoxification and WILL be required to start BTC’s program over once you have completed detoxification.

Do you smoke?

YesNo

Do you use smokeless tobacco?

YesNo

We discourage smoking but allow it in designated areas and at specified times only. Cigarettes only; - vapes, e-cigs, roll your own or any other form of tobacco are NOT allowed. You are responsible for your own cigarettes and we will not take responsibility for providing those for you or replacing any that are misplaced.

We have other rules we expect you to comply with such as limited TV choices and not leaving the grounds without permission, which is a check out offense. You are required to participate in the daily work projects. Work projects are designed to produce discipline and responsibility. We are not a source of income. We are a faith ministry and there is no charge to stay here. There is a non-refundable entry fee and we ask that you send it in before entering the program. We also ask that you bring toilet paper, paper towels, and laundry detergent when you check-in to BTC.

There is also a $30.00 drug-screening fee when you check in to BTC. After that, any time you have a visit you will be required to pay a $30.00 fee before you leave on your visit to cover a drug screening upon your return.

What is your marital status?

Who are you currently living with?

Relationship?

Can you return there when you leave Bethesda?

YesNo

Do you give authorization for us to run a background check?

YesNo

If no, please explain

Have you ever been to jail or prison?

YesNo

If yes, please explain

Do you have any pending charges/court dates?

YesNo

If yes, please explain

Are you on parole/probation?

YesNo

If yes, please explain

Parole/Probation Officer Name

First NameLast Name

Parole/Probation Officer Phone Number

Please enter a valid phone number.

Do you have a prior criminal record?

YesNo

If yes, please explain

Are you a felon?

YesNo

If yes, please explain

Do you have any pending warrants?

YesNo

If yes, please explain

NOTE: If you are a felon you must send a copy of your Criminal Record. If you choose to stay in the Harford County area when you leave Bethesda, we may notify the local authorities. We require that all outstanding legal issues be addressed before entering our program or be postponed until you have completed the program.

The program at Bethesda is for 65 consecutive days and we expect you to make a firm
commitment to fulfill all 65 days.

Is there anything, including finances that would prevent you from doing this?

YesNo

If yes, please explain

How would you rate your overall Health

GoodFairPoor

Do you have any known Drug Allergies?

YesNo

If yes, please list

Must bring an Epipen with you, if needed.

Do you have any disabilities?

YesNo

If yes, please explain fully.

List all limitations

List all treatments

List all medications and dosage amounts you are currently taking/should be taking.

You MUST have ALL prescription medications refilled and enough to last for the 65 day program.

If you are on antibiotics, we must know why you are taking them.

Upload letter from treating Dr. confirming the diagnosis for antibiotic treatment.

Date of your last Hospitalization

Date

Reason for Hospitalization

Date of your last physical exam

Date

Results of last exam

Have you ever had Hepatitis?

YesNo

If yes, which kind?

Date of Diagnosis

Date

Is it in remission?

YesNo

Please upload Dr. note confirming your current status. If Hep C-you will need a Dr. letter stating you will not need treatment while at Bethesda Transformation Center.

Have you ever had TB?

YesNo

If yes, when

If yes, you will need a Dr. note stating you have been cleared and no further signs are evident.

Have you tested positive for HIV?

YesNo

If yes, when

Have you ever been diagnosed with schizophrenia and/or a personality disorder?

YesNo

If yes, what was the diagnosis?

Have you been diagnosed with any sexually transmitted diseases?

YesNo

If yes, which ones?

Have you been diagnosed with any of the following conditions?

You must have a TB and HIV blood test as well as a pregnancy test done prior to being called to come to BTC. (Flu shot is required from October through March, you will need to have a flu shot with documentation.) These test results may take up to a couple of weeks. You will not be placed on the active waiting list until we received at least one of the test results.

Email results to: hello@bethesdatransformation.org

Or mail to: Bethesda Transformation Center PO Box 644 Churchville, MD 21028

You need to take care of any dental, vision or any other medical issues before entering this program. We are not a medical facility nor do we have available the transportation to take care of non-emergency medical needs.

Absolutely no medications on the DEA's list of scheduled medications will be allowed, such as: xanax (alprazolam), klonopin (clonazepam), suboxone, etc. (This is not an all inclusive list.)

If you have any open wounds of infections, they must be treated and healed before you enter BTC. This includes injection sites for IV drug users. You must be free from all infectious diseases, such as Staph, MRSA, and Strep. (Herpes must be dormant.)

Is there anything else you can think of that would help us minister to you?

You are required to have someone bring you to our facility. (You cannot drive yourself.) Who will transport you to and from our location?

First NameLast Name

These are the items you will need:

 Bring work and dress clothes

Some that are not allowed are: no words or photos with drugs, tobacco, alcohol, or anything contrary to a Christian lifestyle; no tight fitting pants without a long top covering them; no low cut tops. No spaghetti straps; no short-shorts.

 Bring your own washcloths, towels, and pillows. (mark your name on them) Bed linens are provided.

 Bring your own personal toiletry items which must be unopened, EXCEPT FEMININE PRODUCTS, they will be provided for you. Tampons are NOT allowed.(nothing with alcohol, ie; mouthwash, perfumes, or aerosols)

 Bring a cloth mesh 36 x 24 laundry bag, bookbag, and a watch. (These items can be purchased at Wal-Mart.)

 Vitamins which are new with the seal unbroken.

 Napkins, toilet tissue, paper towels, facial tissues, laundry detergent (POD's
recommended), and toiletries that must be unopened.

 Bring a Bible if you have one.

These are the items that are NOT allowed:
**NO BODY PIERCING RINGS OR STUDS WORN ANYWHERE ON YOUR BODY!! (except earrings)**

 Personal bed linens are NOT permitted.

 No audio or video apparatus: CDs, DVDs, MP3, IPods, Video Games, etc.

 No over the counter medications.

 No caffeinated drinks, coffee, or pills.

 No provocative clothing either daily wear or sleep wear.

 NO cell phones, tablets, or smart devices.

We are offering to help you overcome your bondage, however, this must be on our terms, are you willing?

YesNo

Do you still want to come?

YesNo

If you have any questions, please email BTC: hello@bethesdatransformation.org and we will respond. Please keep in contact with us throughout the application process.

I have answered all of the above questions on this application honestly and to the best of my ability.

YesNo

I HAVE READ THIS ENTIRE APPLICATION AND AGREE TO FOLLOW ALL THE GUIDELINES SET IN PLACE BY BETHESADA TRANSFORMATION CENTER. BY SIGNING, I PROCLAIM I HAVE ANSWERED HONESTLY TO THE BEST OF MY ABILITY. I UNDERSTAND ANY ANSWERS GIVEN WHICH ARE FOUND TO BE INACCURATE MAY BE REASON FOR ME TO BE ASKED TO LEAVE THE FACILITY.

**Please read the following notes of interest before submitting your completed application.**

I have read and will comply with the above regulations.

YesNo

Signature

Date

IF YOU HAVE ANY QUESTIONS REGARDING THIS APPLICATION PLEASE CALL OUR OFFICE AT 443-966-7632.

Within 72 hours of receiving your application someone from our office will call you to complete your application process. WHEN WE CALL, Bethesda Transformation Center (BTC) MUST SPEAK TO THE PERSON APPLYING. In the case that we have not talked to you within the 72 hours please contact our office to complete your application process. Please make sure that you have filled in the contact phone numbers where you can be reached.

**REMEMBER**
After completing and submitting your application we will need the results of two blood tests (HIV and TB) and the $500.00 Entry Fee before you will be called to come to BTC. Once entered into the program this Entry Fee is non-refundable.

There are now two ways to pay your Entry Fee:

Mail a money order to: Bethesda Transformation Center PO Box 644 Churchville, MD 21028. If you are paying by money order please make sure you write the applicant's name on the "For" line.
Pay your Entry Fee online. There is an additional non-refundable fee for the online payment of your Entry Fee.

Student Application

Personal Information

Drug Usage History

Relationship/Living Status

Legal Concerns

Health Related Issues