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180 MINISTRIES – WOMEN & WOMEN WITH CHILDREN

TEEN CHALLENGE OF THE RM

Student Application for Program Admission

Phone: 970-323-6013 | Fax: 970-323-9853

intake@180women.net

ADMISSIONS PROCESS
This is the full application. Please make sure you fill it out as completely as possible.
Personal Data
Name *
Name
Address
Address
Home Phone
Home Phone
Work Phone
Work Phone
In Case of Emergency
Emergency Contact
Emergency Contact
Address
Address
Home Phone
Home Phone
Work Phone
Work Phone
Who referred you to 180 Ministries for Men?
Name (of refferal)
Name (of refferal)
Address (of refferal)
Address (of refferal)
Phone (of refferal)
Phone (of refferal)
Legal History
Are you on probation?
Are you on parole?
Probation / Parole officer name
Probation / Parole officer name
Probation / Parole officer phone #
Probation / Parole officer phone #
Public Defender / Attorney name
Public Defender / Attorney name
Public Defender / Attorney phone #
Public Defender / Attorney phone #
Do you have any of the following that are pending?
Are you legally mandated to participate in a drug treatment program?
Method of reporting
Military HIstory
Have you ever served in the US Armed Forces?
Date of entry
Date of entry
Date of discharge
Date of discharge
Parents
Fathers Name
Fathers Name
Address
Address
Mothers Name
Mothers Name
Address 4
Address 4
Family History
Are you adopted?
Where you raised by someone other than your parents?
Check any of the following words that best describe you now:
Marital History
List your present living arrangement (check all that apply)
Current spouse's name
Current spouse's name
Current spouse's phone #
Current spouse's phone #
Insurance Information
THIS INFORMATION IS FOR OFFICIAL USE ONLY AND WILL NOT BE RELEASED TO UNAUTHORIZED PERSONS.
PERSONAL / FAMILY MEDICAL HISTORY
Have you ever struggled with the following?
Are you receiving medical care?
Are you on any prescribed medication including psychiatric?
Do you have any special diet requirements?
Have you ever experienced or presently have a physical ailment, injury, or handicap that would prevent you from performing manual, work related tasks while enrolled in Teen Challenge?
Do you smoke or use tobacco in any form?
Teen Challenge has a no smoking or tobacco use policy. Are you willing to abide by this policy?
Drug use history
Check all that apply
To the best of your knowledge, which of the following substances has the applicant used?
Arrests and Convictions
Financial Status
Spiritual History
Date you attended program
Date you attended program
Significant Life Events
Which of the following have you personally experienced?
Sexual Lifestyle
Check all that apply
Check all of the statements that are true in your life.
Academic History
Occupational History
Psychological History
Have you ever though about suicide?
Are you currently thinking about suicide?
Have you ever attempted suicide?
Date of most recent attempt
Date of most recent attempt
About You
Please give us a chronological , bio sketch about who you are, your childhood, any major issues you have had or are now having. This may include your schooling/education, your relationship with your parents, step parents, siblings, etc. We would like to know anything you would like to tell us about who you are:
Todays date
Todays date

Once the application is submitted please download the Student Packet below.  It contains a few documents that you must sign and submit with your application.  You can submit it via email, fax, or bring them to the office.