Dream Run 5K
Adopt a Bed
YOUR NEW LIFE STARTS TODAY
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American Indian/Alaskan Native
Date of Birth (mm/dd/yyyy)
Primary Phone Number
Secondary Phone Number
Do you have children?
Have you ever served on active duty in the U.S. military?
Do you have any pending charges? (please put charges in space below)
Charges (include States with Charges)
Do you have an Attorney or Public Defender?
Attorney or Public Defender contact information
Do you give the Troy Dream Center permission to contact your Attorney or Public Defender?
Are you on Probation or Parole? (If so please fill out box below)
Who is your Probation or Parole Officer ( give officer's contact information below)
Do you give the Troy Dream Center permission to contact your Probation or Parole Officer?
Drug of Choice
When did you last use? What did you last use? (give dates)
List below any Mental or Physical health diagnosis you've had and when. (if no put NA)
List medications you are currently on and why (if none put NA)