APPLICATIONStart your new path of life today! Name: * First Name Last Name Date of Birth * MM DD YYYY Age: * Phone: (###) ### #### Email: * Emergency Contact: * Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Forms of Valid Identification (Check All That Are in Your Possession): * State Issued Driver's license State Issued ID Birth Certificate Social Security Card Passport Marriage License Military ID None Gender at Birth: * Male Female Maritial Status: * Married Single Children (Name, Gender, and Age): * Any Upcoming Court Dates: * Any Current, Pending, or Past Charges: * Is the Court Committing You to Teen Challenge? * Do You Have Any Civil/Legal Lawsuits You are Involved In? * Yes No Are You on Probation or Parole? * Yes No How Did You Hear About Us? * Internet Search Family/Friend Church Facebook Other Current Prescription Medications? * Yes No Please List Your Medications. * Health Conditions (Physical/Mental): * Are you Required to Register as a Sex Offender or Arsonist? * Sex Offender Arsonist Neither Where Do You Currently Live? * Your own house/apartment Staying with someone Homeless Have You Been Enrolled in Teen Challenge or a Similar Program Before? * Please Briefly Describe Why You Are Seeking Help. * Thank you!
