Interest Application
1.
Full Name:
2.
Phone Number: (By providing your number you authorize Teen Challenge to send you text messages regarding your application)
3.
Another Contact's Phone Number or Email:
4.
City:
5.
State:
6.
Zip Code:
7.
Gender at Birth:
8.
Age:
9.
Do you have physical forms of ID such as a Driver's License or Social Security Card?
Both Driver's License and Social Security Card
Only Driver's License
Only Social Security Card
Other (please specify)
10.
Do you have any legal charges pending?
Yes
No
11.
If Yes, what for?
12.
Have you been probated or committed to Teen Challenge by the Court?
Yes
No
13.
Do you have any warrants?
Yes
No
14.
If Yes, what for?
15.
Are you presently taking any prescribed medications?
Yes
No
16.
If Yes, what medications?
17.
Do you have shelter currently?
Yes
No
18.
Briefly tell us your current situation or why you are applying for Teen Challenge?
