Application Form

Personal Information

(mm/dd/yyyy)
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Social Status


Education


Religious Information


Driving Record


Personal Medical History

Rate yourself in the following conditions:

(If none, answer "None")
(If none, answer "None")
Current Medications
(If none, answer "None")
Medical Responsibility

We are not a medical facility, nor are we equipped to provide medical care. We will need to know who shall be responsible for medical expenses should they occur while you are here.

If you have no insurance, please provide the following contact information for the person who will be responsible for your medical expenses:

Additional Information

Please list all other drug/alcohol facilities you have attended, the date, and if you completed the program.

(If none, answer "None")
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Legal Issues

(** We do not meet the requirements of the Parole Board, so parolees cannot be accepted. **)
(If none, answer "None")
(If none, answer "None")

(If yes, you will need to get the date postponed / continued until after you graduate)

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Personal Letter


Pastoral Reference

You will need to have your pastor fill out and send in the "Pastoral Reverence" form that you can find .


Financial Responsibility

Financial obligations will be discussed upon inquiry. Some scholarships are available.


Agreement and Release

By clicking the Submit button below you are indicating that you have read, understand, and agree with the terms in our page.

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