I, {fullName}, acknowledge that I have made an application/desire to be transferred into the program of Adult & Teen Challenge of Sandhills, NC, Inc. (hereafter referred to as ATCSandhills). This is a written acknowledgment of my awareness of the applicable fees that I will be solely responsible for as well as any voluntary financial support that may be required of me, if applicable.
(1) I understand that I am responsible for the non-refundable Admissions fee of $800 and a Physical & Lab fee of $100.
(2) I understand that I must pursue assistance from family, friends, and other concerned parties to help with the cost of Adult & Teen Challenge for me to go through the program.
(3) I understand that any and all costs for medical bills (health providers, dental and eye care, emergency room care, prescriptions and medications, etc…) regarding my own personal health-related issues will be solely my responsibility.
(4) I understand that there may be a transportation fee for any personal transportation that I may need the ATCSandhills to provide me while in the program. This includes transportation to any non-emergency medical appointments, transportation to public transportation (i.e. airport, bus station, etc…) for approved passes, and transportation to the same for return to an Induction Center, other referral sources, or my final departure from the program. I agree to pay the ATCSandhills all transportation fees in advance of appointments being made or travel plans being executed.
(5) I understand that it is my responsibility to apply for food stamp benefits that I may be entitled to while enrolled in the Adult & Teen Challenge. I understand that I will contribute 100% of all food stamp benefits to the ATCSandhills monthly.
(6) I understand that any other sources of income I receive while enrolled in the program (i.e. disability, pension/retirement benefits, insurance settlements, income tax returns, liquidated assets, benevolence assistance, etc…) will be subject to my willful contribution to the ATCSandhills up to the equivalent amount of total food stamp benefit ($192/month) I would have been entitled to if not for these other sources of income. I will surrender the specific amount to the ATCSandhills monthly.
(7) I understand that I will be financially responsible for any damage to property of the ATCSandhills which I caused while enrolled in the program.
(8) I understand that any unpaid fees will necessitate the withholding of the “Certificate of Graduation” until all fees are paid at the ATCSandhills.
(9) I understand that any accidental bodily injury incurred by me while fulfilling my work therapy assignment while at the ATCSandhills does not qualify me for Workman’s Compensation claim. Accidental Medical Expense coverage, as provided by the ATCSandhills, may not cover my accidental medical expenses. Otherwise, I am fully responsible for any and all medical expenses that I may incur.
(10) If admitted to the program with a valid prescription for medication, I agree to take the medications, as prescribed by my doctor. I understand that failure to comply with this policy may lead to dismissal from the program.
(11) I understand that there is an optional program add-on for five Licensed Professional Counseling sessions during the first 30-days in the program. The one-time fee for this add-on is $300. I understand that I will have the option to pay this fee upon submitting this application or by completing the Financial Agreement with my admissions counselor.