Application Requirements
Please take the time to download and read the BC Teen Challenge student manual prior to applying.The student manual will familiarize you with Teen Challenge and help you understand what the program will entail. Prior to acceptance into the program you will also be required to have your doctor complete the medical form listed below. Please print this form and take it to your doctor.

(download the student manual here )
(download the Medical Form for Men )
(download the Medical Form for Women )

Contact Information
First Name:
Middle Name:
Last Name:
E-Mail Address:
Current Address:
City:
Province:
Postal Code:
Phone Number:

Emergency Contact Information
Emergency Contact:
Relationship to You:
E-Mail Address:
Contact Address:
Contact City:
Contact Phone:

Additional Applicant Information
Gender:		[choose one] Male Female
Place of Birth:
Date of Birth:		January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955
Health Card Number:
Health Card Province:
Citizenship:		Canadian CitizenLanded Immigrant
Fluent in English:		TrueFalse
Highest Grade Completed:
Height:
Weight:
Do you have any children:		YesNo
If yes, how many :
Who will care for them while you are in the program:

Which center are you applying to?		[choose one]
Why are you applying to Teen Challenge for help?
Why are you applying to us  instead of another program?
Who referred you to us? Please include phone number:
Describe your lifestyle concerning drugs and alcohol during the past six months:
Do you have, or have you ever had, a psychiatric condition? Explain.
Are you currently taking prescribed medications? Why? Give details:
Do you have a history of violence? Please give details:
If you are in jail, what is the name and address of the institution?
Do you have any court cases pending? If yes, what for?
Are there any outstanding warrants for your arress? If yes, what for?
Is there a restraining order against you? Explain.
Are you currently on a disability or other pension?:		[choose one] Yes No
Please mention any other information we should know:

Agreements
1.	I understand that the BC Teen Challenge program is twelve months long. The Induction Phase of the program is six months long with completion based upon progress in counselling and academic completion of assignments. Once I complete the Induction Phase then the Training Phase of the program begins, which is an additional six months of applying what was taught in Phase One. The Training Phase is based on the ability to handle a more strenuous curriculum and to demonstrate a willingness to grow stronger spiritually, emotionally, and behaviourly with God's help.
2.	I understand that BC Teen Challenge is primarily a Christian discipleship training center where the primary goal is a student's wholeness through the power of God.
3.	I understand that BC Teen Challenge is an interdominational Christian treatment program.
4.	I agree to participate in daily Christian classes for approximately 4 hours per day.
5.	I agree to participate in daily manual labor as part of the work detail program for approximately 4 hours per day.
6.	I agree to participate in one-on-one counselling and will cooperate fully as a student in the program.
7.	I agree to fully participate in the organized recreation program as bart of my basic training.
8.	I understand that BC Teen Challenge expects students to quit all tobaco, drugs and alcohol cold turkey. NO EXCEPTIONS
9.	I understand that BC Teen Challenge's policy is no smoking, no fighting, no girlfriends/boyfriends and that hair styles and clothing must be modest to our expectations, and that phone calls, visits, passes, music, and television are extremely limited, and that all mail is screened. I also undestand that all students communication via phones, mail, visits or passes must be approved in advance.
10.	I understand that there is a high emphasis on rules, structure and discipline and I agree to fully cooperate with the program.
By submitting this application, I indicate that I have read the above agreements and hereby acknowledge my full understanding and commitment to cooperate with the rules of this residential drug rehab program. I also understand and agree that a breach of these rules and/or principles will subject me to disciplinary action and/or loss of privileges and/or dismissal from the program.