Introduction to Teen Challenge
A Message to Students
Welcome to Alabama Teen Challenge, one of the oldest, largest and most successful
discipleship ministries for helping people get set free from addictions.
Thank you for your confidence in Teen Challenge. We are honored that you are considering
entrusting yourself to our care in this delicate season of your life.
Teen Challenge is one of the most successful faith-based recovery programs in the world; we
contribute our success to our foundation in faith. We believe that true change comes from
what God can do on the inside of us. If you are interested in faith-based recovery, Teen
Challenge is the place for you. All of our classes, counsel, and environment are rooted in a
belief in God and values found in the Bible. We are serious about faith-based recovery
because it has provided the most successful care available for overcoming addiction and
beginning a new life.
Teen Challenge is a “Culture of Responsibility.” Our basic premise is that one must assume
responsibility for his own life. You must own the responsibility for your thoughts, choices, and
life patterns. Difficult experiences can contribute to life controlling addiction but cannot be a
reason for remaining in addiction. At Teen Challenge you will take a responsible look at your
life so healing can occur and important lessons can be learned. Your negative experiences do
not need to dictate your future.
Coming into Teen Challenge can be difficult at first. When drugs and alcohol wear off, and you
find yourself away from all that’s familiar a variety of emotions can be experienced. Feelings of
anger, pain, guilt, homesickness, or even being trapped, can creep in on you. As badly as you
know you need to begin this journey, this “internal war” can be most difficult. Experience tells
us that once an individual passes through this initial struggle they will adjust to the program.
You have probably had moments where you wanted things to be different, but were unable to
break the cycles of addiction. We are determined to help you get your life back. No one can
lead your life but you; we want to help you become that responsible leader!
A Message to Families
Families will need to be strong. We must shut the door on every excuse to leave the program
prematurely. As brave as the student may appear, fears of facing the challenge of changing
~1~
their life is real. The family’s natural instinct is to relieve pain, but there’s no growth without it.
We need families to stand strong as we help the student take a hard look at their life. Teen
Challenge must have the family’s support throughout the process of change. Whenever they
communicate pain, encourage them to stay the course and refuse to support a departure from
the program.
When you have questions about what is communicated to you from your student through
phone calls or letters, please contact their assigned Life Coach. We want you to have
perspective as we assist your loved one toward recovery from the devastation of addiction.
Teen Challenge, a Culture of Responsibility
God wants us to know freedom from addiction and destructive behavior. While the world
promises freedom outside of God’s established boundaries, this road leads to entrapment and
a life out of control. It is Teen Challenge’s desire to help you take back that control. Regaining
control begins when you allow God to change your heart and continues as you learn to live
responsibly. There will be some pain in the change as we begin to assume responsibility for our
thoughts, choices, the company we keep, the places we go, how we treat others, or react to
mistreatment. In this “Culture of Responsibility” all of our excuses begin to go but the internal
adjustments we need to govern ourselves, honor God, and respect our fellow man will follow in
their place.
Teen Challenge creates an environment where you can experience God. Seeing life as God
sees it will begin the growth process. Here you will establish new boundaries and enjoy the
freedom that comes from living within them. This is the time and the place where you can face
your fears, your failures, and your disappointments. You can become all that God intended for
you to be.
…Continued
The following are some of the components that make up a responsible culture:
1. Reverence for God.
This is where order begins to come to our lives. It all starts with learning God’s word.
From God’s word we learn:
 That God has a plan for our lives. We’re not on earth to just eat, drink, and be merry.
God has a higher purpose for us than coping with our addiction. You will discover God’s
plan for your life as you journey through the program.
 How God feels about things. When we see how God feels about things we begin feeling
different about the way we’ve been living. This brings conviction into our lives and lets
us know we are accountable for our behavior.
~2~

God can forgive anything that I’ve done. God wants to remove the shame you feel
from the things you’ve done. You haven’t gone so far that God can’t reach you.
2. Respect for others.
There can be no true relationship without respect. To respect is to feel or show honor or
esteem for others. We can learn to respect the boundaries that others set and have
meaningful relationships. We can also discover the value of respecting our leaders and
remaining under the protection their counsel provides.
3. Repentance- learning to admit to God when I’m wrong while having the desire to be
changed. Many of us work hard to stay in a state of denial when it comes to facing our
problems. To admit being wrong would be to admit defeat. This is one battle you must lose.
The refusal to face your “self” will mean the continuation of failure, disa ppointment and broken
relationships. The road to freedom will begin as you become painfully honest with yourself.
When we are honest, the power of God comes to make things right.
4. Retribution-the reward for right and correction for wrong done.
There are always consequences for our behavior whether they are immediate or not. The good
times should always be good and the bad times always bad. To cushion the consequences of
our choices denies us vital self governing information. We fully expect that you will have some
negative behavior while at Teen Challenge. In the past, you may have had enabling
relationships that allowed you to continue your negative behavior; or, a co-dependant
relationship where someone else felt responsible for your addiction and refused to confront
your behavior. In Teen Challenge’s “Culture of Responsibility” you will be held responsible to
face your actions. It is our belief that when you have no place to put the blame but yourself
that you’ll see the need to ask God to help you change.
5. Restitution- learning to make things right when we’ve been wrong. This may involve
returning property we’ve stolen or agreeing to repay someone for damages we’ve caused.
Learning to confess to others and make things right is essential to clear our hearts and minds
for a new way of living. Having to clean up after yourself helps to train the heart to do what’s
right in the future.
6. Restoration- learning to ask for forgiveness, having a willingness to forgive others, and the
commitment to rebuild trusting relationships. Where you have people you will have
differences. The program will provide opportunities to apply restoration principles. Learning
to grow through our differences will prepare us for lasting and meaningful relationships once
we return to society.
7. Rejoicing. Once you embrace the culture there will be plenty of reasons for celebrating. As
you believe and embrace these principles you will discover God’s presence in your life. The
evidence of God’s presence in your life will help you know that you belong to God. Knowing
that you are not alone makes it easier to trust that you can become all that God has intended
for you to be.
Our Heritage
~3~
In 1958, a young preacher by the name of David Wilkerson was in his Pennsylvanian
home reading a Life Magazine about seven gang members in New York City who were on trial
for the murder of a young man. As he read, he felt a strong wave of compassion come over him
and felt as if God was nudging him to go and minister the love of Christ to these young gang
members.
David began to see that the problems these young people were facing were very deeprooted and that there was a need for consistent discipleship in their lives. The idea for a
residential discipleship program arose and began to develop. Out of this work “Teen Challenge”
was birthed.
Nearly 60 years later, Teen Challenge has spread throughout this country and around
the world. Currently, we operate over 1,300 programs in over 115 countries, most of which are
here in the United States. God has used Teen Challenge to rescue thousands of adult men and
women, juvenile boys and girls from the snares of addiction, failure, and sin. Teen Challenge
International is a one-year residential discipleship program geared for life controlling problems,
offering help, hope, and healing to those addicted individuals looking for a change in their life
and life-style.
Featured Program Components
Teen Challenge is not a clinical drug & alcohol treatment program, despite its success amongst
that population. So while Teen Challenge largely, intentionally, & successfully ministers among
an addicted population, Teen Challenge is an arm of the local church seeking to evangelize &
disciple people with life-controlling addictions.
Educational Program
Consists of 2 tracks of study:
1. Group Studies – A fundamental tool in the process of developing a deeper relationship
with God. The fourteen classes teach biblical principles & give the tools to practically
apply them to the students’ everyday life.
 How Can I Know That I am A Christian?
 Love and Accepting Myself
 Overcoming Temptation
~4~
 Attitudes
 Anger & Personal Rights
 Obedience to God
 Obedience to Man
 Christian Practices
 Personal Relationships with Others
 How to Study the Bible
 Successful Christian Living
 Spiritual Power & the Supernatural
 Growing through Failure
 A Quick Look at the Bible
2. Personal Studies –These are personally customized to meet the individual student’s
needs, worked at the student’s own pace, lined with lessons designed to help a student
come to grips with their personal problems.
These studies include:





Scripture memorization
Character Qualities memorization
Goal work
Bible book & chapter outlines
Book reading & Book reports
Vocational Program
 Every student will be assigned work details while they are a student...kitchen
duty; cooking; lawn care, maintenance; etc.  We endeavor to help our students develop good works habits & skills Church Attendance
 Every Sunday each student will attend a church/chapel service along with the
other staff and students. ~5~
 There will be chapel services at each center – attendance is mandatory.  Church Rallies – some students will be asked to be on a ministry team from
that center...this is a time for the student to share what God is doing in their
life. Our residential program is a loving, disciplined, and structured environment.
An example of our daily schedule is provided for your reference.
Teen Challenge is about a total life commitment to an ultimate relationship by the student with
Jesus Christ. We believe that addiction is sin and that we must begin at the root problem as well
as address the effects of the problem in the student’s life. A student will never understand their
own value in the world until they understand their true identity and value in Christ. True
discipleship is learning Jesus by experience. This ministry is marked by the presence of God.
Discipleship is what we are all about.
Program Narrative
Students have opportunity to participate in:
Group & Personal Education Studies
 Character Development
 Goal Setting & Time Management
Group and Personal Mentoring
Student Leadership Program
 Develop leadership skills
 Team building skills
 Master supportive roles
 Learn conflict resolution
Job Skills Development
 Food Management
 Maintenance
 Landscaping
 Impactful Chapel Services
 Mentor Groups
~6~





Internships
Community Outreaches
Personal Relationships
Social skills development
Recreation
Participation Will Result in:
 Acquisition of knowledge.
 Integrated changes in attitude, perspective, and values.
 Behavioral changes evidenced by character development.
 Relationship reconciliation.
 Measurable academic growth.
 Positive & productive work ethic.
~7~
Statement of Faith
As a Christian organization, we regard the following statements as our sound doctrine of faith,
based upon the holy and inspired word of God, the Bible. All students enrolled at Alabama Teen
Challenge are required to attend chapel services, Sunday worship services, and participate in
the Teen Challenge International Group & Personal Studies for New Christians and character
building curriculum.

We believe that the scriptures are inspired by God and declare His design and plan for
mankind. II Timothy 3:15-17

We believe there is only one true God, revealed in three persons …Father, Son, and Holy
Ghost. Matthew 28:19 / Isaiah 43:10-11

We believe in the Deity of the Lord Jesus Christ, that as God’s Son, he was both human and
divine. Matthew 1:23 / Philippians 2:9-11

We believe that man willingly fell into sin, ushering evil and death, both physical and
spiritual into the world. Romans 5:12-19

We believe that every person can have a restored fellowship with God through salvation, by
accepting Christ’s offer of forgiveness for sin. Acts 10:37 / Romans 10:13-15 / Ephesians
2:8-9

We believe in water baptism by immersion after repenting of one’s sins and receiving
Christ’s gift of salvation, and in the Holy Communion, (the Lord’s Supper) as a symbolic
remembrance of Christ’s suffering and death for our salvation. Matthew 28:19 / I
Corinthians 11:26

We believe the Baptism in the Holy Spirit is a special experience following salvation. Acts
1:4, 8 / Mark 16:20

We believe that the physical evidence of the Baptism in the Holy Spirit is “speaking in
tongues” as experienced in the book of Acts. Acts 2:4 / I Corinthians 12:4-10

We believe that sanctification initially occurs at salvation and is a progressive lifelong
process of separation from evil. Romans 12:1-2

We believe that the “Church” is the body of Christ and consists of those people, throughout
time, who have accepted God’s plan of redemption (regardless of religious denomination)
~8~
through the sacrificial death of His son Jesus Christ. I believe this Church has received the
Great Commission to go into all the world to share the Gospel of Jesus Christ. Ephesians
1:22-23 / Hebrews 12:23

We believe in a divinely called and scripturally ordained leadership ministry tha t serves the
Church, i.e. apostles, prophets, pastors, teachers, evangelists).
Mark 16:15-20

We believe that divine healing of the sick was provided for in Christ’s atonement. James
5:14-16

We believe in the “blessed hope” – when Christ raptures His church prior to His return to
earth (the Second Coming). I Thessalonians 4:16-17

We believe in the millennial reign of Christ when He returns with His saints at His second
coming. And at that time the nation of Israel will accept Him as Messiah. Matthew
14:27,30 / Revelation 1:7

We believe that a final judgment will take place for those who have rejected Christ. They
will be judged for their sin and consigned to eternal punishment in a lake of fire, a literal
place called hell. Matthew 25:46 / Revelation 19:20

We believe in and look forward to a perfect New Heavens and a New Earth that Christ is
preparing for all people, of all time, who have accepted Him as their personal Lord and
Savior. We will live and dwell with Him there forever following His millennial reign on earth.
2 Peter 3:13 / Rev 21:22
Information Packet & Application for Enrollment
Teen Challenge Residential Program
Teen Challenge is a 12 month, Christ-centered, residential program for life-controlling
behaviors and addictions. Teen Challenge has two phases called Induction, Training and
~9~
an additional phase of Internship. The first two phases are mandatory for completion,
with the third phase being optional for student, post-graduation. We serve adult males,
eighteen years of age and older.
Monthly Costs
$450 - Monthly Tuition
 This is approximately 1/3 of our monthly cost to house, feed, and train each
student for the course of one year.
$950 - Induction Fee:
 Induction and monthly tuition fees should be made payable by cashier’s check or
money order made out to Alabama Teen Challenge.
 Credit card will be kept on file as an option for recurring payments.
Phone Interview
A personal or phone interview is required with all applicants. Upon acceptance, an entry
date will be set contingent on available bed space.
For an interview call 205.763.0909 and ask for the Director of Admissions.
Physical Health
A blood test for HIV, Hepatitis A-B-C, TB and VDRL will be required as a prerequisite for
enrollment. Student must have all test results prior to entry into the program.
Identification - A picture I.D. and a social security card are needed.
We are already praying for you, even as you fill-out this application.
We look forward to welcoming you to the Alabama Teen Challenge family!
Application for Enrollment
Confidential
Personal Data and Information:
Name:
Last
First
M.I.
Address:
Street
Home Phone:
City
Work Phone:
~ 10 ~
State
Zip Code
Weight:
Height:
Social Security Number:
Driver’s License Number
Driver’s License:
Valid
If Suspended, Why?
In Case of Emergency, Contact:
Address:
Street
Home Phone:
Relationship:
Hair Color:
Eye Color:
Birth Date:
Age:
State:
Expired
Suspended
City
Work Phone:
State
Zip Code
WHO REFERRED YOU TO TEEN CHALLENGE:
Name:
Last
First
Address:
Street
City
State
Phone Number:
Relationship:
Zip Code
RACE / ETHNIC BACKGROUND (Please Circle Only One)
Caucasian
Japanese
Haitian
Puerto Rican
Cuban
Filipino
African American
Chinese
Asian
American Indian
Other
Are you an American Citizen:
Explain:
Yes
Native
PERSONALITY INFORMATION
Is it easy for you to express your feelings?
Explain:
Yes
Naturalized
No
No
Sometimes
Do you enjoy being with other people, or would you rather be alone?
Explain:
PERSONAL FAMILY HISTORY
List Parent/Parent Figures, Spouse, Boyfriend, Brothers, Sisters, and Children
NAME
RELATIONSHIP
AGE
RESIDENCE
(Use the back of this page if additional space is required)
Check the word that best describes your relationship with your parents as a child and now:
As a Child
Now
Very Good
~ 11 ~
Good
Average
Fair
Poor
For the following questions please circle the answer that applies:
Are your parents still living? Father: Yes or No
Mother: Yes or No
Father’s Name:
Age:
Mother’s Name:
Age:
Are you adopted? Yes or No
Were you raised by anyone other than your parents? Yes or No If yes, please explain:
When did you last see your parents?
When did you last live at home?
Occupation: Father:
Mother:
Parent’s marital status: Married Divorced Separated Remarried Living Together
If married, how long?
If other, how long?
How would you rate their marriage? Very Happy - Happy - Average - Unhappy
How would you rate your childhood? Good - Fair - Poor Why?
Growing up, whom did you feel closest to? Father Mother
Other
MARITAL / INTIMATE RELATIONSHIP HISTORY
For the following questions please circle the answer that applies:
Marital Status: Single Married
Separated Divorced
Remarried
Widowed
List your present living arrangement:
Living Alone
With Parents
With Spouse
With Others (non-relatives)
With Others (relatives, children)
Other:
If you are, or have been married, please list: (start with most recent marriage)
Person Married To:
Month/Year Ended In
Month / Year
Current Spouse (full name)
Address:
Street
City
Home Phone (
)
Work (
Describe your relationship with your spouse:
Do you have any children? Yes No
Name of Child
Age
Zip
)
If yes, pleas list:
Where Living
(Use back on this page if additional space is re quired)
Described any positive or negative aspects of your relationship with your children:
~ 12 ~
Describe any problems or concerns related to your relationship with your spouse or boyfriend:
Have you been sexually abused? Yes
No
To your knowledge, has anyone in your family ever been sexually abused? Yes No
When:
Who:
When:
Who:
When:
Who:
Sexual Lifestyle: (please circle all that apply) Bi Sexual
Heterosexual
Homosexual
Pornography
Prostitution
Any recently involved?
Have you engaged in homosexual activity? Yes No Explain:
MILITARY SERVICE HISTORY
Have you ever served in the U.S. Armed Forces? Yes
If yes, describe:
No Explain:
Branch of Service:
Date of Entry:
Date of Discharge:
Military Occupation Standing:
Rank Attained:
Discharge Received (circle): Honorable Less than Honorable Dishonorable
Eligible for V.A. Medical Benefits? Yes No Unknown
LEGAL HISTORY
Are you legally mandated to participate in a Teen Challenge type program? Yes No
If yes, by whom? Parole Board Court Other Explain:
If answer is Court, please county of origin:
Are you currently or will you be under legal supervision? Yes No
Method of reporting: Phone Letter In person Explain:
How often do you report?
How Long?
Time Remaining?
Probation or Parole Officer’s Name:
Agency:
Phone Number:
Address:
Street
City
State
Zip
Are any of the following pending against you? (please circle those that apply)
Arrest Warrant
Court Appearance Criminal Charges Sentencing
Other Explain:
If you have checked any of above, please explain:
List all arrests and convictions:
Date
Charges
Conviction
Yes or No
Sentence
~ 13 ~
Time in Jail
Were alcohol, drugs,
or both involved?
Have you ever been in prison?
DATE
INSTITUTION
SOCIAL INVOLVEMENT HISTORY
Describe your involvement in the following:
Religion
Recreation / Sports
Peer Groups
Community Affiliations
Hobbies
Other
ACADEMIC HISTORY
List the highest grade that you have completed:
Are you currently in an education program? Yes No
If yes, list:
Name of School
City
If you are no longer in an education program, please explain your reason for leaving school:
Are you receiving or have you received vocational training?
TYPE OF TRADE
OR SKILLS
Yes No If yes, list:
DATE OF TRAINING
(Mo/Yr to Mo/Yr)
CERTIFICATE ISSUED
Yes or No
Can you read? Yes No Good Average Poor
Can you write? Yes No Good Average Poor
Describe your future educational and vocational training goals and plans:
Educational:
Vocational:
OCCUPATIONAL HISTORY
What is your vocational trade or profession, if any?
How many jobs have you held in the last two years?
Check your present employment status:
___Unemployment (have not sought employment in last 30 days)
___Unemployment (have sought employment in the last 30 days)
___Employed part-time (working less than 35 hours per week)
___Employed full-time (working 35 hours or more per week)
~ 14 ~
List your two most recent jobs? (Begin with your most recent job)
Name of Employer
Position Held
Employed from Mo/Yr to Mo/Yr
Reason for Leaving
Name of Employer
Position Held
Employed from Mo/Yr to Mo/Yr
Reason for Leaving
List your current average monthly income: $
Describe your primary source income:
Describe your future occupational goals and plans:
Employable Skills:
Have you ever experienced or presently have a physical ailment, injury, or handicap that would
prevent you from performing manual work-related tasks while enrolled in Teen Challenge?
Yes or No If yes, please explain:
PREGNANCY HISTORY
List number of pregnancies:
Have you experienced any of the following problems?
Miscarriages: Yes or No
Abortions: Yes or No
Other Problems (please specify)
Do you think that you might be pregnant now? Yes or No
PSYCHOLOGICAL HISTORY
Have you even received mental health treatment? Yes or No If yes, please list:
Date
Name of Clinic
Reason for Mental Health Treatment Outcome
(Use the back of this page is additional space is required)
Has a family member or someone close to you ever attempted or committed suicide? Yes or No
Have you ever thought about committing suicide? Yes or No
Are you currently thinking about committing suicide? Yes or No
Have you ever received psychiatric care? Yes or No
If yes, please explain:
Will you, as a student of Teen Challenge, be willing to authorize doctors or agencies involved in
previous treatments to release you medical records? Yes or No
~ 15 ~
INSURANCE INFORMATION
List your health insurance type: (please circle)
No health insurance
Other private insurance
Medicaid / Medicare
Other public funds
Insurance policy number:
Company:
Blue Cross/ Blue Shield
Phone:
PERSONAL / FAMILY MEDICAL HISTORY
Please check the appropriate box for any family member that has experienced any of the following problems:
Grandpt.
Father
Mother
Spouse
Brother
Sister
Drug Abuse
Alcoholism
Physical Problems
Mental Health Problems
Describe any illness and developmental problem/concern you experienced as a child:
Do you have any special diet requirements?
If yes, please explain:
Yes or No
When were your teeth last examined?
Are you currently experiencing problems with your teeth? Yes or No
If yes, please explain:
If you drink coffee, teas, or smoke cigarettes, please list the amount you consume each day:
Cigarettes:
packs smoked per day
Coffee:
cups consumed per day
Tea:
cups consumed per day
List how often you used the following drugs (Never, Once, Several Times, or Regularly)
Alcohol
Glue
Barbiturates (downers)
Tobacco
Amphetamines (uppers)
Marijuana
Heroin
Crack
Cocaine
Crank
Hallucinogenic
Others (specify)
Opium
List your present physician’s name:
Address:
Street
Phone Number:
SPIRITUAL HISTORY
Are you born again?
City
Date:
~ 16 ~
State
Place:
Zip
Child
What is your current spiritual condition?
What were the circumstances that led to this?
Denominational preference?
How often do you attend church? Never Occasionally Regularly
Are you a member of any church or religion? Yes No Which one?
How often did you attend church as a child?
Which Denomination was it?
How old were you when you stopped attending?
Why did you stop attending?
Do you believe in God? Yes No Uncertain
Do you pray? Never Occasionally Often
How often you read the Bible? Never Occasionally Often
Do you read books of other religions instead of the Bible? Never Occasionally Often
Which ones?
What recent changes have you had in your religious life (if any)?
Have you ever been involved in cults, such as Christian Science, Jehovah’s Witnesses, Mormonism,
Scientology, TM, Eastern Religions, or others? Explain:
THE PROBLEM
What is your main problem, as you see it?
What have you done about it?
What are your greatest needs in order of priority?
Have you ever been in a program before?
Was it religious or non-religious?
How many programs have you been in before?
Dates:
Reasons for leaving:
List program name 2:
City/State:
Dates:
Reasons for leaving:
Have you ever been in a Teen Challenge program before? Yes or No
When?
Where?
Why did you leave the program? (Circle one)
Dismissed by Staff
Left on own
Completed Program
Other
Why do you wish to be admitted?
~ 17 ~
Graduated
What are you expecting (believing) God to do in your life through the program?
Describe what you are willing to do, or what you think is required of you:
What would you like to do after you leave Teen Challenge?
The undersigned student applicant fully acknowledge that the information provided herein is
accurate and true to the best of her knowledge, and that the application form has been completed
and filled out by student applicant in her own handwriting. Student applicant further understands
that any false or incomplete information may cause and result in disqualification from
admittance into the program, whether a student is just entering into or is in fact in the program.
Student Applicant
Date
If the enclosed application form has been completed or filled out by anyone other than the
student applicant, please provide the following:
1. Name of the person completing and filling out the application form:
Date
2. Relationship to the applicant:
3. Explain why the student applicant was unable to complete or fill out the enclosed application
form:
Health Screening Form
TO BE COMPLETED BY PHYSICIANS ONLY
Today's Date ________________
. Name _________________________D.O.B.____________________
~ 18 ~
. Present Illness/Complaint/Disabilities, if any:
______________________________________________________
_____________________________________________________
. Allergies:
______________________________________________________
______________________________________________________
. Medicine currently prescribed and reason:
______________________________________________________
______________________________________________________
. Has client been exposed to any communicable diseases: Yes No
If yes, please specify: ______________________________________________________
______________________________________________________
. . History of chronic or major illness:
______________________________________________________
______________________________________________________
…Continued
. Operations:
______________________________________________________
______________________________________________________
. Hospitalizations:
_____________________________________________________
~ 19 ~
Physical Examination
Code: Satisfactory = S
Unsatisfactory = U
Not Examined = O
Height _______ Weight _______ B/P _______
Pulse
_______Respirations _______ Temperature ________
General Appearance (including schemata of drug abuse)
Nutrition__________________________________________________
Head ________________________
Ears ____________________________
Hearing: R ________ L ________
Eyes ____________________________
Vision:
(without glasses) R _______ L_________
(with glasses)
R________L_________
Mouth/Teeth _______ Throat_________ Neck/Thyroid________
Nose _______ Chest _______ Hernia _______ Cardiac_________
…Continued
Abdomen_________ Genitalia____________ Musculo-Skeletal_____
Skin___________ Neurological____________
Required Blood Tests:
______Hepatitis B & C
~ 20 ~
______HIV
Required Tests:
______TB
Required Test (Female):
______Pregnancy
______Pap Smear
General comments, assessments, and recommendations on above:
__________________________________________________________
__________________________________________________________
Signature of examining Physician:
_________________________________________________________
_________________________________________________________
(Address) _________________________________________________
__________________________________________________________
(Phone Number)
____________________________________________
Attach computer printouts of all test results before mailing application.
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What to Bring
You will need to bring the following with you:
 Two forms of ID (Picture ID & Social Security Card)
 Return bus fare or pre-paid ticket (Included in the Induction Fee)
 Clothes hangers (no more than 20)
 A Bible
 Notebook, paper, pens, pencils
 Postage stamps, envelopes, and phone card for long distance calls
 1 pillows, 1 set of bed linens (twin size)
 Medical and dental insurance information (if applicable)
 Copy of marriage certificate (if married). This is required for visitation and off-campus
passes with spouse.
 Court Orders (for adjudicated students).
 At least one dress outfit, dress shoes, dress pants/skirt, shirt with collar.  Enough personal hygiene products to last for 60 days. This includes personal toilet
paper and laundry detergent. We do not make shopping trips unless it is an emergency,
so please plan ahead. This includes any approved medications.
 Laundry basket  Enough towels and wash clothes for one week. Shower sandals.  Enough casual clothes for one week. ~ 22 ~
…Continued
 Enough work clothes for one week.  Sheets to fit a twin bed. Pillow and blanket.  NIV or King James Bible (Men) NLT Bible (Women) However, any version of the Bible is
fine, but these are the ones we use most often.  Individually wrapped, hard candy.  Envelopes, stationary, and stamps.  Writing utensils, paper/3 ring binder, notebooks, etc.  A list of projected court dates, if you have any. We require families to transport
students to court. Please plan ahead. Forbidden items:
Please do not bring digital devices (cell phones, cameras, ipods/mp3players, burned compact
disks or DVDs). Please do not bring t-shirts or items that have cigarette ads, alcohol ads,
sexually suggestive material, gang related emblems, non-Christian music or reading material.
Please do not bring any substance that can be huffed or consumed such as , but not limited to,
mouthwash with alcohol, rubbing alcohol, aerosol cans, etc. Anything kept back as contraband
must be returned to your home within 30 days or it will be destroyed. All tobacco products,
lighters, illegal drugs, drug paraphernalia, gum and/or unwrapped candy will be destroyed upon
entrance. You and your personal belongings will be searched upon entrance into Alabama Teen
Challenge.
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ATC Financial Agreement
FIRST MONTH ENROLLMENT FEES
First Month Tuition
$450
Induction Fee:
Return bus fare (in state)
Return bus fare (out of state)
$950.00
$150.00
$200.00
TOTAL DUE UPON ENROLLMENT $1600.00
Personal or Cashier’s Check, Money Order, Credit or Debit Card
INDUCTION FEES ARE NON-REFUNDABLE - The undersigned party understands and agrees that whether
the said student remains at Alabama Teen Challenge for one day or the full twelve (12) months, your paid
induction fees are non-refundable. This includes all processing fees incurring employee time, curriculum fees,
medical fees, and return bus fare. THERE WILL BE NO PRORATING OF TUITION UPON EARLY WITHDRAWAL.
LATE TUITION will result in the following actions:




Notification by e-mail/mail will be sent when payments are not received by the fifth (5 th) day following the
Due Date.
If no payment is received after the tenth (10 th) day following the Due Date, a call will be placed to you by
our office.
Failure to bring the account up-to-date within thirty (30) days following the due date will result in the
dismissal of the student from the ATC program.
All prepaid tuition & Induction Fees are non-refundable upon dismissal.
MEDICAL FEES - The undersigned party will assume responsibility for all medical and dental expenses i nc ur r ed
during the time this agreement is in effect. Alabama Teen Challenge will charge a $20 roundtrip transportation fee
will be charged to the student cash account for each doctor or dentist visit. Other transportation needs such as
academic testing (GED/ACT) will accrue the same fee.
I warrant and attest that I have read, understand, and accept the above statement for students entering the
Alabama Teen Challenge.
Dated this _________ day of _________ 20_________
____________________________
(Printed Name of person(s) responsible for payment)
___________________________
(Signature of person(s) responsible for payment)
ATC Student Tuition Agreement
It has been explained to me, and I understand, that the monthly tuition for Alabama Teen
Challenge is $________ per month.
~ 24 ~
I agree to pay tuition costs in the amount of $_______ per month throughout the duration of
my program.
Due to the monthly cost to keep one student in Alabama Teen Challenge, we are asking the
student who does not meet the entire amount for monthly support which we request from
them, to give Teen Challenge the liberty of deducting 50% of any money the student receives
for their personal account. This will enable the student to help pay for their own way through
the program. This deduction will also apply for those lacking Induction Fee until it is paid in full.
This agreement will be in effect throughout the entire program.
I also agree that if I decide to leave the program pre-maturely, all funds, regardless of the
amount brought in which would include donations and funds in my student account will
automatically become property of Teen Challenge.
I warrant and attest that I have read, understand, and accept the above statement for students
entering the Alabama Teen Challenge.
Dated this _________ day of _________ 20_________
____________________________
(Printed Name of person(s) responsible for payment)
___________________________
(Signature of person(s) responsible for payment)
~ 25 ~