Microsoft word - dtc_application_package.doc

611 3rd & North Street
Seaford, Delaware 19973
Office: (302) 629-2559
Fax: (302) 629-8824

Disqualifying Factors for Admission:

1) Persons who have records of sex offenses which presents a risk to the community. 2) Individuals with legal restraints which would preclude them from participating in the program and which cannot be sorted out by our Admissions office with the legal authority. 3) Individuals with medical problem which requires excessive time away from our residential program. 4) Individuals taking mind altering or mood changing prescriptions. PERSONAL INFORMATION
Name of girl/boy friend (if applicable): d:\delaware teen challenge\dtc_application_package.doc

Do you have any children?
Name of Child
With Whom Residing
Parent’s marital status while you were living with them: Married Were you raised by someone other than your parents? PHYSICAL HEALTH INFORMATION
Rate your health in the last year to present: List all important present or past illness, injuries, or handicaps with the approximate year of occurrence: Do you have any special dietary requirements?

Have you had recurring convulsions, epilepsy, or fainting spells at any time in the last 5 years?
Are you presently on medication (including over-the-counter)? Are any of these medications used to treat depression, anxiety, pain, or sleep disorders? Are you currently in treatment for mental health reasons? If yes, please list the name and phone number of the doctor whose care you are currently under: Do you have any health problems that would limit you from complying with the rules and/or standards of this program? (examples would be standing, sitting, or light work detail) Do you currently have to see a doctor on a regular basis? If yes, please list the name and phone number of the doctor whose care you are currently under: Are you currently experiencing any dental problems? If yes, please give the name of your insurance provider: If no, who will be paying your medical bills should an emergency arise?:
Disclaimer: Delmarva Teen Challenge reserves the right to prohibit entrance to individuals taking mind and/or mood-
altering medications (e.g., Lithium, Prozac, Haldol, Ritalin, Valium, etc.)

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

Also Note: All students accepted into Delmarva Teen Challenge must have a tuberculosis test administered. RESULTS of
that test must be submitted on the day of entry.

Do you have any cases/warrants/tickets pending? Are you presently on probation or parole? If yes, give name, address and phone number of agent: Please also give the name, address and phone number of your attorney: ACADEMIC BACKGROUND
List the highest grade that you have completed: Grade School EMPLOYMENT BACKGROUND
What is your vocational trade or profession, if any? Who was your last employer (company name & supervisor’s name):

May we contact your employer if necessary?
If yes, please give your local number as well as your union rep’s name and phone no.: Did your employer refer you to Delmarva Teen Challenge? Have you ever served in the U.S. Armed Forces? SPIRITUAL BACKGROUND
Are you currently affiliated with any church? No If yes, please give the following information: Have you ever been involved in the occult? Have you ever been involved in cults such as Christian Science, Jehovah’s Witness, Mormonism, Islam or others? Have you ever been involved in a homosexual/lesbian lifestyle? How would you describe your present spiritual condition? OTHER INFORMATION
Have you ever been in a Teen Challenge program before? List how often you have used the following drugs: (never, once, several times, or regularly) REASON FOR ENTRY INTO DELMARVA TEEN CHALLENGE
Why do you want to enter Delmarva Teen Challenge? What have you done about your problem before now? How do you think Delmarva Teen Challenge will help you? REASON FOR ENTRY INTO DELMARVA TEEN CHALLENGE (Cont’d)
If accepted into Delmarva Teen Challenge are you willing to commit to at least 1 year? Yes No Do you have any financial obligations that would prevent you from fulfilling this commitment? The undersigned student applicant fully acknowledges that the information provided herein is accurate and true to the best of his or her knowledge, and the application form has been completed and filled out by the student applicant in his or her own handwriting. The student applicant further understands that any false or incomplete information may cause and result in disqualification from admittance or continuation in the program. The undersigned student gives permission for Delmarva Teen Challenge to contact any of the heretofore mentioned people and/or institutions. The undersigned student also understands that his residency at Delmarva Teen Challenge is at the will of Delmarva Teen Challenge and may be terminated at any time and for any reason. Upon your reading and understanding of each of the items listed below, put your first and last initials on each of the lines to indicate your agreement to each of the statements. I agree to paying the full $500.00 tuition fee. I understand that I will be expected to pay an additional $500.00 per month during my residency in the program. I am aware that all fees are NON-REFUNDABLE. I understand that I will be expected to have all my fees paid upon my personal pass times. Should these fees be unpaid, I agree to forfeit this time until such fees are paid. Should an outside job be available, I agree to working on personal pass time and contributing all monies earned to Delmarva Teen Challenge toward my unpaid fees. Should I be coming from a city or town outside the Seaford area, I agree to having a round trip ticket (bus/train/plane) prior to entrance into DTC (or the appropriate funds to purchase the said ticket). I will also have transportation fees available which will be placed on hold ($5.00 bus/train station; $10.00 airport). Should I leave before graduating, I understand that monies in my personal student account above $5.00 will be returned in the following manner: a. by check b. within five (5) working days; and c. mailed to the address I indicate Monies will be withheld should I have any outstanding financial obligations to DTC (e.g., induction fee, personal account debits). Furthermore, monies will become the property of Delmarva Teen Challenge in the event that I do not give an address to forward remaining account monies within thirty (30) days of my departure. I agree to donating to Delmarva Teen Challenge 50% of all SS/SSI income I am presently receiving. I am aware that I am not permitted to apply for SS/SSI income while a student at Delmarva Teen Challenge. I understand that I will have to discontinue pursuing these funds upon entrance into Delmarva Teen Challenge should I have already applied. I understand that I forfeit my right to receive Unemployment Compensation while a Upon entering the program, I give Delmarva Teen Challenge permission to inspect all of my personal belongings. I give permission for authorized personnel to read all my incoming and outgoing 10. I understand that it is my responsibility to take all of my belongings with me at the time of departure or to make special arrangements to pick them up. I understand that I am NOT permitted to take any “blessings” with me should I leave before my graduation date. 11. I am aware that should I be dismissed or decide to leave of my own volition, I will be expected to exit Delmarva Teen Challenge properties within a 2-hour period. 12. I give permission for authorized personnel to contact the person(s) indicated on my INFORMATION” form in the event that I am dismissed from the program or leave of my own volition. 13. I understand that Delmarva Teen Challenge is NOT responsible for any personal 14. I understand that Delmarva Teen Challenge cannot and will NOT be held responsible personal injury occurring while in the program. 15. I will notify staff of any job detail that I feel would be a risk to my personal safety. I will exercise reasonable care in regards to any work detail. 16. I am ___ I am NOT ___ on prescribed medication* (check one). List medications if *Note: If you are currently on prescribed medication, you must complete and
sign A Student Medication Agreement Policy Form

17. I understand that I will not be permitted to receive outside counseling as a student of 18. I have read and agree to abide by the written Rules and Regulations for as long as I am a student in the Delmarva Teen Challenge program. If I have any questions regarding these rules, I agree to ask a staff member for clarification. 19. I agree that I am signing this form under no compulsion by a DTC staff member, intern, or volunteer, nor anyone else affiliated with Delmarva Teen Challenge. I am voluntarily and willingly entering into this agreement of my own volition. 20. I understand that my residency at Delmarva Teen Challenge is at the will of Delmarva Teen Challenge and may be terminated at any time and for any reason. I have read each of the 20 items on this form or have had them read to me in their entirety. I understand the contents of this form and I consent to each of the conditions listed above. Signed: Men’s Center Checklist
$500.00 cash or money order (non-refundable) - No personal checks Money for return bus fare (if out-of-town) Collared shirts (for chapel & classes) Shampoo, soap, toothpaste, toothbrush, etc. Phone card and stamps - we will hold for your use Hard candy (individually wrapped, such as Jolly Ranchers) NIV Bible (Old and New Testament) NO books, magazines, cassette tapes or cd’s Other: PHONE NUMBERS: 302-629-2559 Main Center


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