DATC Seaford Men's Program Application

  • Disqualifying Factors

    1) Individuals who have records of sex offenses which may present a risk to the community due to the City of Seaford's regulations and restrictions. 
    2) Individuals with legal restraints which would preclude them from participating in the program and which cannot be sorted out by our Admissions office with the legal authority.
    3) Individuals with medical problems which requires excessive time away from our residential program.
    4) Individuals taking pschycotrophic medications (mind-alterling,mood-altering medications, sleep-aids, etc).

  • Delmarva Adult & Teen Challenge

    Men's Center Application

  • Personal Information

  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Race*
  • Ethnicity*

  • Family History

  • Do you have any children?*

  • Are you adopted?
  • Parent's marital status while you were living with them?

  • Physical Health History

  • Are you experiencing any of the following? (Please check all that apply)*
  •    
  • Do you have any health problems that would limit you from complying with the rules and/or standards of this program?
  • Are any of these medications used to treat depression, anxiety, pain, or sleep disorders?*
  • Have you had recurring convulsions, epilepsy, or fainting spells at any time in the last 5 years?*
  • Are you currently experiencing any dental problems?*
  • Are you currently in treatment for mental health reasons?*
  • Have you been treated for any health conditions in the last year?*
  • Are you diabetic?*
  • Do you have any special dietary requirements or allergies?*
  • Do you currently have to see a doctor on a regular basis?*
  • Do you have medical insurance?*
  • Rows
  • Have you ever attempted suicide*
  • Have you previously committed to a drug treatment program?*

  • Disclaimer: Delmarva Adult & Teen Challenge reserves the right to prohibit entrance to individuals taking mind and/or mood- altering medications (e.g., Lithium, Prozac, Haldol, Ritalin, Valium, etc.)

    Please note: All medications used to treat depression, anxiety, pain and sleep disorders or other psychological problems are carefully screened at Delmarva Adult & Teen Challenge. Please consult your doctor before considering entry.

    Also Note: All students accepted into Delmarva Adult & Teen Challenge must have a tuberculosis test administered. RESULTS of that test must be submitted on the day of entry.

  • Legal Status

  • Do you have any tickets, warrants, cases pending?*
  • Are you currently on parole or probation?*

  • Miscellaneous History

  • Highest level of education you have completed*
  •    
  • Have you ever been accepted to a Teen Challenge before?*
  • Are you currently affiliated with any church?*
  •  -
  • Have you ever been involved in the occult?*
  • Have you ever been involved in other religions such as Christian Science, Jehovah's Witness, Mormonism, Islam, or Others?*
  • Have you ever been involved in a homosexual lifestyle?*

  • Employment History

  • May we contact your employer if necessary?*
  • Format: (000) 000-0000.
  • Do you belong to a union?*
  • How long did you hold your last job?*
  • Have you ever served in the U.S. Armed Forces?*
  • Discharge received*

  • Reason For Entry

  • If accepted to Delmarva Adult & Teen Challenge are you willing to commit to at least 1 year?*
  • Do you have any financial obligations that would prevent you from fulfilling this commitment?*

  • Student Agreement Form

  • I agree to sign and comply with Delmarva Adult & Teen Challenge's Medication Agreement Policy Form before entry

  • Signature and Submission

  • The undersigned student applicant fully acknowledges that the information provided herein is accurate and true to the best of his or her knowledge, and the application form has been completed and filled out by the student applicant. The student applicant further understands that any false or incomplete information may cause and result in disqualification from admittance or continuation in the program. The undersigned student gives permission for Delmarva Adult & Teen Challenge to contact any of the heretofore mentioned people and/or institutions. The undersigned student also understands that his residency at Delmarva Adult & Teen Challenge is at the will of Delmarva Adult & Teen Challenge and may be terminated at any time and for any reason.

  •  - - :
  •  
  • Should be Empty: