Resident Application

17667 Pierson | Detroit, MI 48219 | 313.531.0111 (toll-free 844.355.LIFE) | lcm.life
1230 Dupont | Flint, MI 48504 | 810.424.9039 (toll-free 844.355.LIFE) | lcm.life

Find Your Freedom

Adult & Teen Challenge/Life Challenge Ministries (ATC/LCM) has an enduring commitment to support equality by affirming the value of diversity and by promoting an environment free from discrimination. No person shall be denied admission based on any legally prohibited discrimination involving, but not limited to, such factors as race, color national origin, gender, age or disability.

The following could be disqualifying factors for admission: Individuals who have records of *Criminal Sexual Conduct (CSC). Individuals with legal restraints that cannot be resolved in advance by our Resident Services Department, and which would preclude them from participating in the program. Individuals with medical problems that require excessive time away from our residential program.

Please note: All medications used to treat depression, anxiety, pain and sleep disorders or other psychological problems are carefully screened at ATC/LCM. Please consult your doctor before considering entry.

Disclaimer: ATC/LCM reserves the right to prohibit entrance to individuals taking certain medications. Prior to entry, all residents must have Tuberculosis (TB), HIV, Hepatitis B, and Hepatitis C tests administered and results submitted to ATC/LCM by the day of entry. Women are required to also submit pregnancy test. All residents must get a physical exam within 30 days of entering the program.

 
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PERSONAL INFORMATION
CHURCH AFFILIATION
EMERGENCY CONTACT
EDUCATION & EMPLOYMENT
List your three most recent employers:
FAMILY HISTORY
Please provide your significant other's contact information:
CHILDREN
HEALTH & TREATMENT
Please provide your treating physician's contact information:
Please provide your doctor's contact information:
NeverOnceSeveral TimesRegularly
Alcohol
Amphetamines (uppers)
Barbiturates (downers)
Benzodiazepine (benzo)
Cocaine
Crack
Hallucinogens/Glue
Heroin
Marijuana
Methadone
Other
ABUSE HISTORY
Select all that apply
CRIMINAL HISTORY
(Date, Charges, Convicted Yes or No, Sentence, Time Incarcerated)
Please provide your agent's contact information:
Please provide your attorney's contact information:

Waiver, Release and Hold Harmless Agreement

WHEREAS, Life Challenge of Southeast Michigan provides education, meals, lodging and other considerations for the duration of the resident's studies at no cost other than a minimal admissions fee, and

WHEREAS, in consideration of the willingness of Life Challenge of Southeast Michigan, its leadership faculty, staff, interns, volunteers and board to offer these benefits, in the Spirit of Christ and for the benefit of its residents, the resident willingly executes this Waiver, Release and Hold Harmless Agreement:

NOW THEREFORE, the resident on behalf of him or herself and his or her heirs, assigns and all other persons or entities claiming by under or through the resident, represents, covenants and agrees as follows:

  1. The resident acknowledges that in the course of providing services Life Challenge of Southeast Michigan or its faculty members, residents, employees, officers, agents or representatives might cause injuries, death, property damage or other harm to the resident or to third parties. The resident accepts and voluntarily incurs all risks of any such injuries, damages, or harm which arise during or result from any activities of or services provided by Life Challenge of Southeast Michigan, its leadership, faculty members, residents, interns, employees, officers, agents, or representatives, except only to the extent caused by the sole negligence or willful misconduct of Life Challenge of Southeast Michigan, its leadership, board or their departments, affiliates, faculty members, residents, interns, employees, officers, agents, representatives, parent organizations or insurers ("Released Parties").
  2. The resident waives, releases and forever discharges all claims against any of Released Parties for any injuries, damages, losses or claims, whether known and unknown, which arise during or result from any activity of or services provided by Life Challenge of Southeast Michigan or any of the Released Parties including but not limited to any such injury, damage, loss, or claim arising from any provided services or activity except only to the extent caused by the sole negligence or willful misconduct of any of the Released Parties.
  3. The resident acknowledges that in the course of providing services Life Challenge of Southeast Michigan or its faculty members, residents, employees, officers, agents, leadership, board or their departments, affiliates, interns, representatives, parent organizations or insurers ("Released Parties") might cause injury, death, property damage or other harm to the resident or third parties. The resident accepts these risks, waives and releases liability, and agrees to indemnify the Released Parties from all injuries, damages, losses, claims, or other harm which arises during, or the result from any activities of or services provided by Life Challenge of Southeast Michigan or any of the Released Parties, except only to the extent caused by the sole negligence or willful misconduct of Life Challenge of Southeast Michigan or by a Released Party.
  4. The resident acknowledges having carefully read and reviewed this Waiver, Release and Hold Harmless Agreement, and the resident represents that he or she fully understands and voluntarily executes the same.
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