RESIDENT APPLICATION

Fill out and submit the resident application below as best you can and we will be in contact with you shortly. 

If you are having troublbe with the form, please
contact us directly by email: bcrc@atmc.net or give us a call href="tel:9102874357">(910) 287-4357

GENERAL INFORMATION

Enter your first name

MaleFemale

Please select your gender.

Enter your dob.

Enter your last name

Please Check Here if You Are Pregnant

Enter your primary phone number (ex: 000-000-0000)

Enter a secondary phone number (ex: 000-000-0000)

SUBSTANCE INFORMATION

YesNo

BCRC is not a medical facility, therefore every resident must be successfully
detoxed before admission to the program. Every prospective resident is asked to submit to a drug and
alcohol test immediately prior to their admission

YesNo

HEALTH INFORMATION

YesNo

YesNo

YesNo

YesNo

BCRC is not a medical facility and does not employ a medical staff. This means that
you may not be accepted as a resident if you are not healthy enough to participate in all aspects of
the program or require regular doctor visits.

EDUCATION INFORMATION

LEGAL INFORMATION

YesNo

(ex: 000-000-0000)

YesNo

BCRC program residents participate in fundraiser trips that are sometimes outside of
NC. This means that you may not be accepted if you cannot leave the state.

YesNo

YesNo

NoYes

Due to BCRC's zoning, we are unable to accept convicted sexual offenders

YesNo

YesNo

FAMILY INFORMATION

(ex: 000-000-0000)

YesNo

YesNo

Residents of BCRC do not have an income during the 16 week program. This means that
arrangements must be made for any financial obligation prior to admittance

ADDITIONAL COMMENTS

E-MAIL

bcrc@atmc.net

PHONE

(910) 287 4357