Life Challenge Resident Application 
Application for Life Challenge WNC Residential Recovery Program
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Email *
Full Legal Name *
Current Physical Address  *
Phone Number *
Date of Birth  *
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/
DD
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Age  *
Weight *
Height *
Race *
Emergency Contact
Name, Phone, Relationship
 *
Marital Status *
Do you have any children? *
If yes to children, how many do you have?
What are the custody arrangements?
What was the last grade you completed? *
Have you ever been in a special educations program? *
If yes, explain. 
To which gender do you identify?  *
What do you consider your sexual orientation?  *
Please list any current charges  *
Please list any pending charges *
Are you currently on probation or parole? *
Name of probation or parole officer: 
Contact information for probation or parole officer: 
(phone, county, and address)
Lawyer's Name and Phone Number: 
Do you believe in God? *
Are you a born again Christian?  *
How would you describe your relationship with Jesus now? 
Please list any mental health issues and the date of diagnoses:  *
Please list any other medical conditions or illness not previously mentioned: *
Please list any medications you currently take: *
Please list any allergies: *
Please list your drug(s) of choice and any substances you have recently abused: *

Please list any treatment centers you have been to and when (detox, inpatient, outpatient, etc.):

 *
Do you currently require detox? *
How long have you suffered from addiction? *
What do you consider your main problems? *
Essay: In your own words, please explain why you chose to apply to Life Challenge, what circumstances led you to this point.
 *
A copy of your responses will be emailed to the address you provided.
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