Student Application Form

Student Application Form - Confidential

Step 1 of 4

Address















Gender at Birth



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
 

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Student Application Form

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