> Admissions Request
> Men's Guidelines
> Women's Guidelines
Please note: We are NOT a treatment center, medical, or detox facility. We are a residential Christian discipleship program. Our facility is male-only. You must be 18 or over to apply. Your Name: Address1: Address2: City: State: --Select a State-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code: Phone No: Email: Please enter the information below pertaining to the individual you are referring. Name: Age: City: State: --Select a State-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Is the person you are referring currently incarcerated? Yes No If so, would you like the director of our prison ministry to make a point of contact with him? Yes No Name of facility: City, State: Phone No: Would you like a Teen Challenge information packet sent to you? Yes No Please type any additional comments in the box provided below.
Please note:
Your Name:
Address1:
Address2:
City:
State:
Zip Code:
Phone No:
Email:
Please enter the information below pertaining to the individual you are referring.
Name:
Age:
Is the person you are referring currently incarcerated?
Yes
No
If so, would you like the director of our prison ministry to make a point of contact with him?
Name of facility:
City, State:
Would you like a Teen Challenge information packet sent to you?
Please type any additional comments in the box provided below.
