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Preliminary student application

Thank you for your interest in the residential program at Christian Encounter Ministries. Please fill out this form as completely as possible.

 

PERSONAL INFORMATION
Applicant's name: *
First Name
Middle
Last Name
Data supplied by:
Applicant's birthdate*
Applicant's gender *
GENERAL INFORMATION ABOUT APPLICANT
Is personally motivated to come to CEM.*
Desires to develop a closer relationship with God.*
Is between the ages of 16 and 25 (female) or 16 and 19 (male).*
Is free from pending legal action.*
Is not required to participate in probation or a diversion program.*
Is able to benefit from a more structured, less complicated environment.*
Desires to work toward emotional and spiritual health.*
Desires to complete academic goals if still in high school.*
Is capable of participating in rigorous physical activities.*
Is free of addictions to alcohol, cigarettes, or drugs, or is willing to detox prior to admission.*
Is not a physical threat to self or others. Does not have a history of violent behavior.*
Please explain any "no" answers above.
CONTACT INFORMATION
email address*
Address
Address Line 1
Address Line 2
City
State
Postal Code
Home telephone number*
Applicant's cell phone
Other contact phone number
Mother's full name
First Name
Middle
Last Name
Mother's address
Address Line 1
Address Line 2
City
State
Postal Code
Father's full name
First Name
Middle
Last Name
Father's address
Address Line 1
Address Line 2
City
State
Postal Code
HISTORY AND FAMILY INFORMATION
Applicant lives with *
Family members (parents and siblings, age of siblings)
Marital status *
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?
MEDICAL INFORMATION
Does applicant have medical insurance?*
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.
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