Online Application Name * First Name Last Name Social Security Number Phone (###) ### #### Email * What is the best way to contact you? Date of Birth * MM DD YYYY Sex at Birth? * Male Female Address Address 1 Address 2 City State/Province Zip/Postal Code Country Marital Status * Single Engaged Married Separated Divorced Citizenship * United States Other Do you read and write at a 5th grade level or above? * Yes No Do you have ND Health Insurance? * Yes No Are you prescribed any medication? * Yes No If yes, are you taking your medications consistently? Yes No If yes, what medications? Are you currently on parole or probation? * Yes No If yes, which State/County? Do you currently have any court cases pending? * Yes No If yes, which State/County? If yes, please list any pending charges and court dates. Do you currently have any outstanding warrants? * Yes No If yes, which State/County? Are you currently facing charges for a violent or sex related crime? * Yes No If yes, please describe. Are you required to register as a sexual or predatory offender? * Yes No In your own words, please tell us why you want to come to North Dakota Adult & Teen Challenge. Also, share the main issues you feel you need to work on while in the program. *
