Resident Application for Admission

Resident Application for Admissionmcbridejessie2019-12-19T03:03:22-06:00

All applicants must complete this application. Falsifying any of the information will be grounds for termination of the application process. If you would rather complete the print version of the application, you may download it and email it to: jackson@youth-reach.org

DOWNLOAD PRINT VERSION OF APPLICATION

- Step 1 of 8

Applicant Contact Information

Name *

First

Last

Date of Birth *

Phone *

Email *

Please enter your email, so we can follow up with you.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

General Information

How did you hear about Youth-Reach Gulf Coast? *

Internet Search
Social Media
Flyer/Brochure
Friend
Other

Are you aware that we are a Christ-centered home? *

We believe that our only hope is freedom in Christ. Would you be open to exploring a true relationship with Jesus Christ, understanding that it may look different than church as you've known it? *

List the locations (cities) you have lived in for the past three years. *

How would you rate your attitude towards submitting to authority? *

Excellent
Fair
Poor

Please describe what your attitude towards submitting to authority has been recently. *

Are you currently involved in a committed relationship (i.e. girlfriend, fiancée, wife, etc.)? *

Do you currently have or support children? *

During the last 12 months, how often did you have any kind of drink containing alcohol? *

Every Day
5-6 Times Per Week
3-4 Times Per Week
Twice Per Week
Once Per Week
2-3 Times Per Month
Once Per Month
3 to 11 Times in the Past Year
1 or 2 Times in the Past Year
Never

Do you or have you ever used recreational drugs? *

If you answered yes to the above question, please explain which drugs you have used, what age you began using drugs and how often you have used drugs in the past 6 months.

Criminal History

Have you ever been charged with or convicted of a crime? *

If you answered yes to the above question, please list all charges even if you have completed your time or probation.

Have you ever been accused or convicted of a sexual offense? *

If you answered yes to the above question, please explain.

Do you presently have a criminal record? *

Are you currently on probation or parole? *

If you answered yes to the above question, please explain the offense(s) and explain the details of your probation.

Do you have any upcoming court dates? *

If you answered yes to the above question, please list the location(s), date(s)/time(s) and charge(s).

Previous Programs

Please enter all of the information below for any other long-term stay facilities you have attended.

Have you ever participated in a long-term residential program? *

Facility #1

Address Line 1

City

State

Zip Code

Date of Entry

Please explain the reason for admittance.

Please explain the reason for termination and result.

Facility #2

Address Line 1

City

State

Zip Code

Date of Entry

Please explain the reason for admittance.

Please explain the reason for termination and result.

Family Relationships

Father's Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Occupation

Mother's Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Occupation

Are your parents divorced? *

If your parents are divorced, are either of them remarried?

How would you rate your relationship with your parents? *

Excellent
Fair
Poor

Please explain why you selected the above rating to describe your relationship with your parents. *

Siblings

Sibling #1 Name

First

Last

Date of Birth

Phone

Sibling #2 Name

First

Last

Date of Birth

Phone

Sibling #3 Name

First

Last

Date of Birth

Phone

How would you rate your relationship with your siblings (brothers/sisters)?

Excellent
Fair
Poor

Please explain why you selected the above rating to describe your relationship with your siblings.

References

Please list information for at least one references (e.g. relative, friend, teacher, etc.) we can contact. Additional references may be requested during the interview process.

Reference #1 Name *

First

Last

Age *

Phone *

Occupation *

Reference #2 Name

First

Last

Age

Phone

Occupation

Reference #3 Name

First

Last

Age

Phone

Occupation

Educational Background

Name of Last School Attended *

Address *

Address Line 1

City

State

Last Grade Completed *

Forms of Identification

Do you have a copy of your birth certificate? *

Please select the forms of ID you have in your possession. *

Driver's License
Social Security Card
State Issued ID
None of These

Medical History

Please note that residents are responsible for all medical bills while in residence at Youth-Reach Gulf Coast.

Have you ever been diagnosed with any of the following medical conditions? *

Rubella
Measles
Mumps
HIV
Heart Disease
Cancer
Tumor
Hernia
Asthma
Bronchitis
Hepatitis
Chicken Pox
Tuberculosis
Vision Loss
Hearing Loss
Stomach Ulcers
A.I.D.S.
Kidney Infection
Venereal Disease
Major Surgery
Psychiatric Issues
Learning Disabiities
Diabetes
Enlarged Heart
Heart Murmur
Eating Disorders
Thyroid Dysfunction
Ulcers
Migranes
Seizures
None of These

Please share any other medical conditions you have been diagnosed with if not listed above.

Primary Physician's Name *

First

Last

Address

Address Line 1

City

State

Date of Last Medical Exam

Date of Last Dental Exam

Do you have any physical disabilities? *

If you answered yes to the question above, please explain.

Have you ever sought psychological or psychiatric help? *

Please select the following issues you have received counseling or treatment for. *

Drugs
Alcohol
Emotional Stability
Depression
Pornography
Sexual Perversion
Homosexuality
Anger/Rage
Bipolar Disorder
Violent Tendencies
Motivation
Suicidal Thoughts
Manipulation
Stealing
Lying
Attention Deficit Disorder (ADD)
None of These

Are there issues other than those listed above that you have received counseling or treatment for? If so, please list them.

Therapist's Name (If Applicable)

First

Last

Phone

Are you currently taking any medication? *

If you answered yes to the question above, please list all medications and dosages.

Are you allergic to any medications? *

If you answered yes to the question above, please list all medicine allergies.

Please list all known allergies.

Resident Statement of Agreement

By submitting this application for admission, I am agreeing to live by all requirements of residency at Youth-Reach Gulf Coast for the duration of my stay. I also understand that repeatedly breaking these established rules will result in my immediate termination from this Christ-centered home. I give permission to the staff of Youth-Reach Gulf Coast to hold me accountable to resident standards.

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What Makes YRGC Different?

We Are a Christian Ministry

We are a Christian ministry built on the foundation of God’s Word. We are not religious, but we take advantage of the power found in a relationship with Jesus to witness the healing of young lives. Firm, compassionate and balanced discipline coupled with clear and predictable boundaries are key elements in this transformation.

We Never Charge a Fee for Our Services

We never charge a fee for our services. We feel strongly that our services should be provided without a parent’s ability to pay the bill being a consideration. This work is not cheap, but we are committed to raising the support so our assistance to families can be offered free of charge.

We Are a Long-Term Solution

We are a long-term solution for the kids that need long-term care. A young man can stay at Youth-Reach for as long as they need a home and continue to make progress. If a guy is in need and remains teachable, they may stay, gain a high school diploma, and leave Youth-Reach for college, or even better, the mission field.

We Are Legitimate

We are legitimate in every way. We are a recognized 501(c)3 non-profit organization and perform yearly independent audits. Our facilities meet or exceed all state and county health, fire and building codes.

We Work with Juveniles & Adults

We work with both juveniles and adults. We care for juveniles from age twelve to eighteenth birthday at our Houston campus, and for adult young males ages of eighteen to twenty-two here on our Summerdale, Alabama campus.

“Youth Reach took me in at this dark, dark time in my life and they loved me. They taught me how to be a son of God and they taught me how to walk out sonship as a son of God.”

Hunter Ricks, Program Graduate

“I was strung out in a mental hospital. I had no where to go but to Jesus and thank the Lord for this place called Youth-Reach Gulf Coast. It was the paradise – literally – that I was hoping for.”

Jackson Bentley, Program Graduate