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Student Application
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Student Application
By
John Richardson
On
December 12, 2010
·
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Day
Month
Year
Name of Applicant
*
First
Last
Current Address of Applicant
*
City
*
State
*
Zip
*
Date of Birth
Day
Month
Year
Social Security #
*
Driver License #
Home Phone #
Mobile Phone #
Email Address
*
Name of Spouse
First
Last
Name of Girlfriend/Boyfriend
First
Last
Address
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Phone#
Do you have any children?
*
Adult Children
Minor Children – Full Custody
Minor Children – Joint Custody
Minor Children – No Custody
No Children
Child Support Agency and Case Worker Information.
Is your Father still living?
Yes
No
Name of Father
First
Last
Is your Mother still living?
Yes
No
Name of Mother
First
Last
Parents
Married
Divorced
Separated
Living Together
Are you adopted?
Yes
No
Were you raised by someone other than your parents?
Yes
No
If yes, please explain:
How would you rate your Health?
Excellent
Good
Fair
Poor
Very Poor
Recently Hospitalized
Are you diabetic or have dietary restrictions?
*
No
Diabetic requiring insulin
Diabetic requiring medication
Non-diabetic w/dietary requirement
Do you have any of the following? Please check all that apply.
*
None
Outstanding Court Cases
Warrants
Tickets Pending
Personal Protection Order
Restraining Order
Are you presently on probation or parole?
*
Yes
No
If Yes, please provide probation and attorney contact information:
Education – Select highest grade completed.
8th grade
9th grade
10th grade
11th grade
Graduate with diploma
GED
College – some
College – degree
List previous employers and last date worked.
May we contact your employer if necessary?
Yes
No
Are you currently affiliated with any church?
Yes
No
If yes, please provide the name of church and Pastor
Please check all of your past religious involvement.
None
Christian Science
Jehovah
Have you ever been in a Teen Challenge program before?
Yes
No
If yes, please provide the location and dates.
Do you currently use any of the following?
Cigarettes
Chewing Tobacco
Steroids (any)
Herbal Supplements
What was your first drug of choice and how often used?
Have you used any of the following drugs?
Alcohol
Barbiturates (downers)
Amphetamines (uppers)
Hallucinogens
Glue
Heroin
Methadone
Marijuana
Cocaine
Crack
Methamphetamine
Why do you want to enter Life Challenge?
As you see it, what is your problem?
What have you done about your problem before now?
How do you think Life Challenge will help you?
If accepted into Life Challenge are you willing to commit to at least 1 year?
Yes
No
Not Sure
Do you have any financial obligations that would prevent you from fulfilling this commitment?
Yes
No
If yes, please explain.
