Resident Application

Submitted by kmack on Fri, 2020-07-31 14:08

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.

Detroit's Testing Center
The Health Center at McKenny
19750 Burt Road | Detroit, MI 48219
313.279.6100

Flint's Testing Center
Hamilton Medical Health
400 Saginaw Street #300 | Flint, MI 48501
810.787.5001

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Please make your best attempt to fill out this application completely.

PERSONAL INFORMATION

Today's Date

Year

Month

Day

First Name

Last Name

Street Address

City

State/Province

Postal Code

Phone Number

Birth Date

Year

Month

Day

Gender at Birth

Female

Male

CHURCH AFFILIATION

Are you currently affiliated with a church?

Yes

Church Name

Pastor's Name

Church Street Address

Church City

Church State/Province

Church Postal Code

Church Phone Number

EMERGENCY CONTACT

Emergency Contact Name

Relationship

Street Address

City

State/Province

Postal Code

Phone Number

FAMILY HISTORY

Marital Status

Single

Married

Separated

Divorced

In a Relationship

Please provide your significant other's contact information:

Name

Street Address

City

State/Province

Postal Code

Phone Number

CHILDREN

Do you have children?

Yes

Name of First Child

Age

With whom they are residing

Name of Second Child

Age

With whom they are residing

Name of Third Child

Age

With whom they are residing

HEALTH & TREATMENT

Rate your health in the last year to present

Poor

Fair

Good

Excellent

List important present or past illness, injuries, or handicaps including year of occurrence:

Do you have any dietary requirements?

Yes

Please explain:

Are you currently on any medication (including over-the-counter)?

Yes

Are any of these medications used to treat depression, anxiety, pain or sleep deprivation?

Yes

List all medications you are taking:

Are you currently in treatment for mental health reasons?

Yes

Please provide your treating physician's contact information:

Name

Phone Number

Do you currently need to see a doctor on a regular basis?

Yes

Please provide your doctor's contact information:

Name

Phone Number

Do you have medical insurance?

Yes

Name of Insurance Provider

Have you ever been in an Adult & Teen Challenge program before?

Yes

Name or Location of Adult & Teen Challenge Center

Date Entered

Year

Month

Day

Date Left

Year

Month

Day

Reason for leaving

Graduated

Left Voluntarily

Dismissed

Please identify any other addiction treatment centers you have been to:

Select how often you have used the following drugs:

	Never	Once	Several Times	Regularly
Alcohol	Alcohol - Never	Alcohol - Once	Alcohol - Several Times	Alcohol - Regularly
Amphetamines (uppers)	Amphetamines (uppers) - Never	Amphetamines (uppers) - Once	Amphetamines (uppers) - Several Times	Amphetamines (uppers) - Regularly
Barbiturates (downers)	Barbiturates (downers) - Never	Barbiturates (downers) - Once	Barbiturates (downers) - Several Times	Barbiturates (downers) - Regularly
Benzodiazepine (benzo)	Benzodiazepine (benzo) - Never	Benzodiazepine (benzo) - Once	Benzodiazepine (benzo) - Several Times	Benzodiazepine (benzo) - Regularly
Cocaine	Cocaine - Never	Cocaine - Once	Cocaine - Several Times	Cocaine - Regularly
Crack	Crack - Never	Crack - Once	Crack - Several Times	Crack - Regularly
Hallucinogens/Glue	Hallucinogens/Glue - Never	Hallucinogens/Glue - Once	Hallucinogens/Glue - Several Times	Hallucinogens/Glue - Regularly
Heroin	Heroin - Never	Heroin - Once	Heroin - Several Times	Heroin - Regularly
Marijuana	Marijuana - Never	Marijuana - Once	Marijuana - Several Times	Marijuana - Regularly
Methadone	Methadone - Never	Methadone - Once	Methadone - Several Times	Methadone - Regularly
Other	Other - Never	Other - Once	Other - Several Times	Other - Regularly

Please specify Other if applicable:

Do you smoke cigarettes?

Yes

Have you ever attempted suicide?

Yes

Please explain:

ABUSE HISTORY

CRIMINAL HISTORY

List all arrests and convictions:

(Date, Charges, Convicted Yes or No, Sentence, Time Incarcerated)

Do you have any cases, warrants or tickets pending?

Yes

Please explain:

Are you presently on probation or parole?

Yes

Please provide your agent's contact information:

Name

Address

Phone Number

Please provide your attorney's contact information:

Name

Address

Phone Number

REFERRAL SOURCE

How did you hear about Adult & Teen Challenge | Life Challenge Ministries?

Please provide their name:

Please specify:

I Agree

I, the resident applicant, fully acknowledge that the information provided herein is accurate and true to the best of my knowledge, and the application has not been completed and filled out without my consent. I further understand that any false or incomplete information may cause and result in disqualification from admittance or continuation in the program. I give permission for Adult & Teen Challenge/Life Challenge Ministries (ATC/LCM) to contact any of the heretofore mentioned people and/or institutions. I also understand that my residency at ATC/LCM is a will of ATC/LCM and may be terminated at any time and for any reason.

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:

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").

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.

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.

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.

I Agree

I have read the Waiver, Release and Hold Harmless Agreement and I agree.

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Resident Application

Find Your Freedom

Waiver, Release and Hold Harmless Agreement