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* 1. Full Name:

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* 2. Phone Number:

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* 3. Another Contact's Phone Number or Email:

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* 4. City:

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* 5. State:

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* 6. Zip Code:

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* 7. Gender at Birth:

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* 8. Age:

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* 9. Do you have physical forms of ID such as a Driver's License or Social Security Card?

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* 10. Do you have any legal charges pending?

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* 11. If Yes, what for?

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* 12. Have you been probated or committed to Teen Challenge by the Court?

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* 13. Do you have any warrants?

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* 14. If Yes, what for?

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* 15. Are you presently taking any prescribed medications? 

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* 16. If Yes, what medications?

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* 17. Do you have shelter currently?

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* 18. Briefly tell us your current situation or why you are applying for Teen Challenge?

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