> Admissions Request
> Men's Guidelines
> Women's Guidelines
Please note: We are NOT a treatment center, medical, or detox facility. We are a residential Christian discipleship program. Our facility is male-only. You must be 18 or over to apply. Name: Address1: Address2: City: State: --Select a State-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code: Phone No: Email: Please indicate your date of birth. --Month-- Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec --Day-- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 --Year-- 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 Please indicate the type of life-controlling problems that you are struggling with. (check all that apply) crack/cocaine meth heroine alcohol other substances pornography homosexuality sex addiction What is your current marital status? single married divorced common law marriage *Note: Common law marriages are not recognized by Teen Challenge as a correct biblical practice and will not be honored. What are your current living arrangements and legal status? own home rent hotel shelter homeless living with someone incarcerated house arrest Are you currently on parole? Yes No Are you currently on probation? Yes No Do you have any court charges pending? Yes No Please write any additional comments in the box provided below.
Please note:
Name:
Address1:
Address2:
City:
State:
Zip Code:
Phone No:
Email:
Please indicate your date of birth.
--Month-- Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec --Day-- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 --Year-- 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985
Please indicate the type of life-controlling problems that you are struggling with. (check all that apply)
crack/cocaine
meth
heroine
alcohol
other substances
pornography
homosexuality
sex addiction
What is your current marital status?
single
married
divorced
common law marriage
*Note: Common law marriages are not recognized by Teen Challenge as a correct biblical practice and will not be honored.
What are your current living arrangements and legal status?
own home
rent
hotel
shelter
homeless
living with someone
incarcerated
house arrest
Are you currently on parole?
Yes
No
Are you currently on probation?
Do you have any court charges pending?
Please write any additional comments in the box provided below.
