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TCR Admission Application
Contact Information
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First Name *
Last Name *
Email Address *
Phone Number *
Only numbers are allowed (no dashes, spaces or parenthesis)
Is it ok to leave you a voicemail identifying TCR? *
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Do you have a valid Driver's License? *
Date of Birth *
Language of choice
Clear selection
Marital Status *
Professional Skills *
Please list skills you have developed throughout your professional/academic career.
Name of Father Confessor *
Phone Number of Father Confessor *
Only numbers are allowed (no dashes, spaces or parenthesis)
Email of Father Confessor
Name of Sponsor (responsible for monthly payment) *
Phone Number of Sponsor *
Only numbers are allowed (no dashes, spaces or parenthesis)
Email of Sponsor *
Sponsor's relationship to you *
What addictions are you currently struggling with? *
Date of latest use: *
Are you physically able to take care of yourself? *
Are you currently receiving EBT (food stamps) benefits? *
Have you ever visited TCR? *
Are you capable of comprehending a program of recovery? *
Are you willing and capable of committing to a 9-month program of recovery without any interruptions? *
Why do you want to join the program? *
How did you find out about this program? *
Are you a registered sex offender? *
Do you have any pending court dates? *
Are you on probation or parole? *
Have you been tested for STDs, Hepatitis? *
List your currently prescribed/over the counter medications. *
Do you have health insurance? *
Name of healthcare provider
Health insurance policy number
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