Resident Application

Please make your best attempt to fill out this application completely.

PERSONAL INFORMATION
Gender at Birth
EMERGENCY CONTACT
CHILDREN
Do you have children?
CHURCH INFORMATION
HEALTH & TREATMENT
Rate your health in the last year to present
Do you have any dietary requirements?
Are you currently on any medication (including over-the-counter)?
Are any of these medications used to treat depression, anxiety, pain or sleep deprivation?
Are you currently in treatment for mental health reasons?
Please provide your treating physician's contact information:
Do you currently need to see a doctor on a regular basis?
Please provide your doctor's contact information:
Do you have medical insurance?
Have you ever been in an Adult & Teen Challenge program before?
Reason for leaving
Have you ever attempted suicide?
CRIMINAL HISTORY
(Date, Charges, Convicted Yes or No, Sentence, Time Incarcerated)
Do you have any cases, warrants or tickets pending?
Are you presently on probation or parole?
Please provide your agent's contact information:
Please provide your attorney's contact information:
REFERRAL SOURCE
I Agree

 

Waiver, Release and Hold Harmless Agreement

WHEREAS, Life Challenge of Southeast Michigan provides education, meals, lodging and other considerations for the duration of the resident's studies at no cost other than a minimal admissions fee, and

WHEREAS, in consideration of the willingness of Life Challenge of Southeast Michigan, its leadership faculty, staff, interns, volunteers and board to offer these benefits, in the Spirit of Christ and for the benefit of its residents, the resident willingly executes this Waiver, Release and Hold Harmless Agreement:

NOW THEREFORE, the resident on behalf of him or herself and his or her heirs, assigns and all other persons or entities claiming by under or through the resident, represents, covenants and agrees as follows:

 

 

 

 

  1. The resident acknowledges that in the course of providing services Life Challenge of Southeast Michigan or its faculty members, residents, employees, officers, agents or representatives might cause injuries, death, property damage or other harm to the resident or to third parties. The resident accepts and voluntarily incurs all risks of any such injuries, damages, or harm which arise during or result from any activities of or services provided by Life Challenge of Southeast Michigan, its leadership, faculty members, residents, interns, employees, officers, agents, or representatives, except only to the extent caused by the sole negligence or willful misconduct of Life Challenge of Southeast Michigan, its leadership, board or their departments, affiliates, faculty members, residents, interns, employees, officers, agents, representatives, parent organizations or insurers ("Released Parties").
  2. The resident waives, releases and forever discharges all claims against any of Released Parties for any injuries, damages, losses or claims, whether known and unknown, which arise during or result from any activity of or services provided by Life Challenge of Southeast Michigan or any of the Released Parties including but not limited to any such injury, damage, loss, or claim arising from any provided services or activity except only to the extent caused by the sole negligence or willful misconduct of any of the Released Parties.
  3. The resident acknowledges that in the course of providing services Life Challenge of Southeast Michigan or its faculty members, residents, employees, officers, agents, leadership, board or their departments, affiliates, interns, representatives, parent organizations or insurers ("Released Parties") might cause injury, death, property damage or other harm to the resident or third parties. The resident accepts these risks, waives and releases liability, and agrees to indemnify the Released Parties from all injuries, damages, losses, claims, or other harm which arises during, or the result from any activities of or services provided by Life Challenge of Southeast Michigan or any of the Released Parties, except only to the extent caused by the sole negligence or willful misconduct of Life Challenge of Southeast Michigan or by a Released Party.
  4. The resident acknowledges having carefully read and reviewed this Waiver, Release and Hold Harmless Agreement, and the resident represents that he or she fully understands and voluntarily executes the same.
I Agree

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