Bluefield Student Application
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Student's Last Name *
Student's First Name *
Student's Preferred Name
if not first name
Contact Information
Street Address *
line 1
Street Address
line 2 (optional)
City *
State *
Zip Code *
Student Phone *
Student Email *
Date of Birth *
mm-dd-yyyy
Family Members
Please identify family members or others who are supporting your application to Bluefield.
Name *
last, first
Relationship *
Phone Number *
Email Address *
May Bluefield contact this person? *
Education
What year are you in school?
What school are you attending or returning to?
When are you scheduled to begin classes?
What are you academic strengths?
What are your academic interests?
Recovery History
Have you completed primary treatment?
If so, where and when?
What is your primary drug of addiction?
How long have you been abstinent?
Do you use tobacco products?
Describe your recovery efforts over the last 4-6 months.
Is your family supportive of your recovery efforts?
Are you currently seeing a therapist?
If so, how often?
Please list current medications
Do you have any allergies?
If so, please list them.
How can Bluefield help you reach your goals?
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