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Broken lives restored in Christ; restored lives reaching the broken.

APPLY

Thank you for your interest in the residential program at Christian Encounter Ministries. Please fill out this form as completely as possible. All fields with an * must be filled out.

PERSONAL INFORMATION

* Indicates required field

Form filled out by: *

First

Last

Applicant's name: *

First

Last

Applicant's Birthday: *

Applicant's Gender: *

Male Female

How did you hear about CEM? *

GENERAL INFORMATION ABOUT APPLICANT

Is personally motivated to come to CEM. *

Yes No

Desires to develop a closer relationship with God. *

Yes No

Is between the ages of 16 and 25 (female) or 16 and 21 (male). *

Yes No

Is free from pending legal action. *

Yes No

Is not required to participate in probation or a diversion program. *

Yes No

Is able to benefit from a more structured, less complicated environment. *

Yes No

Desires to work toward emotional and spiritual health. *

Yes No

Desires to complete academic goals if still in high school. *

Yes No

Is capable of participating in rigorous physical activities. *

Yes No

If addicted to alcohol, cigarettes, or drugs is willing to detox prior to admission. *

Yes No N/A

Is not a physical threat to self or others. Does not have a history of violent behavior. *

Yes No

Please explain any "no" answers above. *

CONTACT INFORMATION

Email address *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Best contact phone number: *

Mother's full name *

First

Last

Mother's email address *

Mother's address *

Line 1

Line 2

City

State

Zip Code

Country

Father's full name *

First

Last

Father's email address *

Father's address *

Line 1

Line 2

City

State

Zip Code

Country

HISTORY AND FAMILY INFORMATION

Applicant lives with *

Family members (parents and siblings, age of siblings) *

Applicant's marital status *

Single Married Engaged Divorced

Work history *

Education *

Educational goals *

Educational problems *

Emotional challenges *

Current counselor *

PERSONAL SUMMARY AND CHRISTIAN EXPERIENCE

Precipitating problems (reason for applying to CEM) *

Christian experience *

Does applicant attend church? *

Yes No

MEDICAL INFORMATION

Does applicant have medical insurance? *

Yes No

Describe any medical/physical problems *

List all medications applicant is taking *

LEGAL PROBLEMS

Report both present and previous legal problems. Please include any upcoming court dates, probation, unfinished community service hours, and any other information that would be helpful. *

Before submitting, make sure you have filled out all required fields (marked with an *). After submission, you will be sent to a new page with an acknowledgement.

Submit

SERVICE TIME:
Sundays @ 9:30 am

OFFICE HOURS:
M-F: 9:00 am - 4:00 pm

CONNECT:
p: 530-268-0877 | f: 530-268-9077
email us
PO Box 1022 Grass Valley, CA 95945

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Home
About Us
Get Involved
Youth Program
Resources
Give