Student Application Form

In what way can you personally contribute financially to the ministry of Teen Challenge?

Personal Walk with God:

I,

, understand and acknowledge that the information provided herein is
accurate and true to the best of my knowledge. I further understand that any false or incomplete information
may cause and result in disqualification from admittance or dismissal from the program.

In the event this application was filled out by another, please identify the reason why the applicant was
unable to complete this for themselves and sign below.

Notice, it is hereby understood that Teen Challenge of Wisconsin will not be held responsible for any personal
property left, lost or stolen while in the Teen Challenge of Wisconsin program. I agree that any property or
money left at Teen Challenge of Wisconsin over 14 days from my departure date, voluntarily or not,
announced or unannounced becomes the property of Teen Challenge of Wisconsin. It is further understood
that there is a $995 induction fee which is payable upon entry into the program and is non-refundable. I also
understand that if I am dismissed from Teen Challenge of Wisconsin or decide to leave the program I must
leave within 24 hours. If I become belligerent, abusive, uncooperative, or threatening I must leave the facility
immediately. It is important that medical, dental, business and legal needs be taken care of before entering
the Teen Challenge of Wisconsin program. If you have such needs that cannot be taken care of before
entering Teen Challenge of Wisconsin please call the center and explain your situation.

Teen Challenge International Wisconsin Centers are committed to helping students become physically,
mentally and spiritually whole. We are not, however, a medical program. We will endeavor to assist you in
securing whatever medical help we can while you are in the program. If you become ill or need medical
attention once you are in the program we will assist in connecting you with a medical facility. You are
responsible for any fees that accrue in connection with your visit to or treatment from any medical facility. We
do not financially assist students in meeting their medical bills.

If you have had a head injury where you lost consciousness or were admitted to a hospital for
evaluation, please give the date and explain the nature of your injury, any medical treatment you
received, and any difficulties that resulted from the injury in the space below. (memory loss, lack of
concentration, headaches, vision problems etc.)

Please use the chart below to describe your use of alcohol and drugs

When answering the question of "How Often Taken", use O for Once, ST for Several Times, R for
Regularly and C for Continuous usage

The undersigned fully acknowledges that the information provided herein is accurate and true to the
best of his or her knowledge. Any false or incomplete information may cause and result in
disqualification from admittance or dismissal from the program.

Downloads

• What to Bring List
• Things Potential Students Need to Know
• Student Communication Policy
• Physical Form for DR.
• Family, Friends Sponsorship Sheet
• Financial Requirements