Student Application Form

Student Application Form - Confidential

Step 1 of 4

Address
Gender
MM slash DD slash YYYY
Drivers License
Have you ever had a moving violation or ticket?
I currently Live with

(indicate "other" for other family member, lock up facility, or other situation)
Indicate below the way in which you were referred to Adult Teen Challenge?

Name
Phone

In Case of Emergency Please Notify

Address

Race/Ethnic Background

Race/Ethnic Background

Are you an American citizen?
Marital Status
Address
Do you have any children?
List
Name
Birthday
Age
Sex
 
Are you court ordered to pay child support?
Do you owe child support?
Are your parents married?
Do they abuse drugs or alcohol?
Are you close to your parents?
Do you have any siblings?
If yes, please list
Name
Birthday
Age
Sex
Do they use drugs or alcohol? (yes or no)
 
Have you ever engaged in homosexual activity?

Military History

Branch of military you've served
MM slash DD slash YYYY
MM slash DD slash YYYY
Discharge Received
Are you eligible for V.A. Medical Benefits?

Legal History

Do you need court approval to enter this program?
Are you currently or will you be under legal supervision?
Are you legally mandated to participate in a drug recovery program?
If yes, by whom?

Method of Reporting

Address
Address
Are any of the following items pending against you?

Do you have any unpaid court costs or fines?
Have you ever been convicted of a sexual offense?
Are you required to register as a sex offender'?
Have you been in a county jail, correctional institution or state prison?
If yes, please List
Date
Institution
 
List any arrests and convictions
Date
Arrest/Charges
Sentence/Time served
 

Get Drug Recovery Help. Find Hope. Be Transformed.

We can also help you in your search for other telephone addiction treatment , addiction treatment centers, addiction treatment, treatment centers near me, low-cost addiction treatment or addiction treatment programs. These Midwest alcohol rehab centers will specifically target alcoholism. Adult & Teen Challenge centers are long-term addiction recovery programs that are affordable, solving addictions for men in Wisconsin and Illinois, from the Chicago area, to Milwaukee and Madison, including Cudahy, South Milwaukee, Elm Grove, Butler, Brookfield, Menomonee Falls, Waukesha, Germantown, Pewaukee, Rockford.

Student Application Form

adult and teen challenge great lakes

Sign up for our newsletter!

Sign up to receive Adult and Teen Challenge news
updates in your e-mail inbox!


Donate to Great Lakes ATC

A donation to Adult & Teen Challenge Christian drug rehabs directly supplies the tools and training those struggling with addictions need in order to overcome them. There are many ways you can help.

Donate Here

Holler Box
MENU