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Are you under the care of any of the following?
Check all that apply.

Alcohol History

Drug History

Have you ever been involved in any recovery programs?
Did you complete the program?
Check all that apply.
Check all that Legal matters that apply.

How much time have you spent? (Years, Months or Days) 






Do you have any siblings?
Did your parents experience divorce?
Were you ever in foster care?
Do you know the names of your birth mother and father?
Are you currently speaking to your parents(s) or guardian(s)




In the Bible, the Word of God – inspired and authoritative In one God who exists eternally in three persons; Father, Son and Holy Spirit. In the Deity of our Lord Jesus Christ, in His virgin birth, in His sinless life, in His miracles, in His substitutionary and atoning death through His shed blood, in His bodily resurrection, in His ascension to the right hand of the Father and in His future personal return to rule in power and glory. We believe that for the salvation of lost and sinful people, regeneration by the Holy Spirit is absolutely essential and that this salvation is received through faith in Jesus Christ as Savior and Lord and not as a result of good works. In the complete forgiveness and eternal salvation of the true believer. In the empowering ministry of the Holy Spirit, who lives in Christians, thereby enabling each to live a godly life In the bodily resurrection, judgement and eternal conscious existence of both the saved and the lost. In the spiritual unity of believers in our Lord Jesus Christ. I have read and understand that Transitional Youth is faith based/Christ centered. 


The information contained in this document will be treated with the utmost confidentiality and respect. Transitional Youth has strict criteria for the treatment and storage of confidential documents. 

Release to Do Reference Checks and Criminal Records Check I authorized my references, present and past employers listed in this application, to give Transitional Youth any information, including opinions, they may have regarding my character and fitness to be employed or volunteer with Transitional Youth. This release and authorization acknowledge that Transitional Youth may now, at any time while employed or as a volunteer, obtain and use a “consumer report” about me, which may include verification of my education, previous employment/work history, driving record, and criminal record that may be in the files of the federal, state, or local criminal justice agency in any state. A photocopy or telephonic facsimile (FAX) of the Authorization and Consent for Release of Information shall be valid as the original. The results of this verification process will be used to determine employment or volunteer eligibility. All results will be kept confidential. The information obtained will not be provided to any parties other than to Transitional Youth personnel, and their professional advisors and consultants if deemed appropriate in either’s sole discretion. I authorize the Oregon State Police Department, or any other company doing business with Transitional Youth that provides background information, to release any information that pertains to any record of convictions in its file or in any criminal file maintained on me, whether local, state, or national, and to disclose orally and in writing the results of this verification process to authorized representatives. I do hereby agree to forever release and discharge Transitional Youth, its interviewers, to the full extent permitted by law, from any claims, damages, losses, liabilities, cost and expenses, or any other charges or complaints arising from the retrieving and reporting information. In the event that information from the consumer reports is utilized in whole or in part in making an adverse decision with regard to my application, before making the adverse decision, Transitional Youth will provide me with a copy of the report and a description in writing of my rights under the law. I hereby authorize Transitional Youth to obtain a consumer report on me. I also certify that all the information that I provided in this application is true and complete. I understand that any false or misleading information may prevent me fro volunteering with Transitional Youth/Braking Cycles. 


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