Interest Application Question Title * 1. Full Name: Question Title * 2. Phone Number: (By providing your number you authorize Teen Challenge to send you text messages regarding your application) Question Title * 3. Another Contact's Phone Number or Email: Question Title * 4. City: Question Title * 5. State: Question Title * 6. Zip Code: Question Title * 7. Gender at Birth: Question Title * 8. Age: Question Title * 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) Question Title * 10. Do you have any legal charges pending? Yes No Question Title * 11. If Yes, what for? Question Title * 12. Have you been probated or committed to Teen Challenge by the Court? Yes No Question Title * 13. Do you have any warrants? Yes No Question Title * 14. If Yes, what for? Question Title * 15. Are you presently taking any prescribed medications? Yes No Question Title * 16. If Yes, what medications? Question Title * 17. Do you have shelter currently? Yes No Question Title * 18. Briefly tell us your current situation or why you are applying for Teen Challenge? Done
