Apply Online - Noupoort Please Fill in the Form Below to Apply for Admission at Noupoort Christian Care Centre (This Information will be Automatically be Delivered to the Program Manager and the Admission Department) Apply Online - All Residents Last Name * First Name * Date of Birth * ID Number of Resident * Age * Gender (Choose) * Male Female Marital Status * Married Never Married Single Boyfriend Girlfriend Engaged Widow Widower Dependants * 1 2 3 4 5 6 7 8 Please Provide a Bit of Background on the Patient * Church Affiliation Pastor's Name Pastor's Contact Number Who Referred you to Noupoort? * Referrer's Contact Number Why Noupoort? * Home Address * Home Language * Contact Email 1 * Contact Email 2 Mobile Number * Home Number * Work Number Other Number Qualifications Profession Hobbies Position Years Employed Court Case Pending - Please List Them * Sponsor Surname * Sponsor Name * Sponsor Relationship * Sponsor Physical Address * Sponsor Language Sponsor Postal Address Sponsor Email * Sponsor Mobile Phone * Sponsor Home Number Sponsor Other Number Family Details - Next of Kin * Relationship to Next of Kin * Mobile Phone * Home Phone * Email * Work / Other Main Drug of Choice * Alcohol Mandrax (Buttons) Tik / Meth Heroin Dagga Khat Crack Ecstacy Meds Cocaine LSD Solvents Other Drugs Tried Alcohol Mandrax (Buttons) Tik / Meth Heroin Dagga Khat Crack Ecstacy Meds Cocaine LSD Solvents Specify Other Drugs, Addictions or Problems Previous Rehabs Attended * Physical Condition * Good Poor Avarage Comments Are you on prescription meds? * Yes No ...if 'Yes', please Explain: Period on Medication Note Regarding Meds Psychiatrist / GP who prescribed the above Medication Are you presently under medical treatment If yes, reason and treatment * No Yes THE ABOVE QUESTION AND BELOW SECTION ARE TO BE COMPLETED TO PREVENT THE APPLICANT FROM FABRICATING AILMENTS TO PREVENT THEM FROM GETTING INVOLVED IN THE PROGRAM. ...if yes, state reason and treatment Time on Treatment Note on the above Have you been tested for any of the below? * AIDS TB Syphilis Hepatitis Any other tests? I agree to be tested for the above while in Noupoort * Yes No MEDICAL HISTORY / INFORMATION * Serious operations Serious illnesses Serious injuries Self mutilation Anorexia Bulimia Notes Any Allergies or Asthma * Any other information with respect to applicant’s physical condition Are you on a Disability Grant? * No Yes If yes, explain... Is the applicant on medical aid (if so please provide details) I hereby acknowledge that all information provided in this application is honest. * Yes No I have read the rules and the attached daily routine and bind myself thereto. * Yes No I agree to have tests done at any given time for drugs and/or alcohol. * Yes No I agree to be tested for AIDS, TB, Syphilis and Hepatitis. * Yes No I understand that should I decide to leave the program before the completion date that NCCC is not obliged to assist me in any way. * Yes No I understand that I will forfeit all funds should I leave the program before the completion date. * Yes No I understand that relapse is not part of NCCC program and the use of any addictive substance during my program at N.C.C.C will result in a new program. * Yes No Should a resident abscond the sponsor/parent must return her/him before 48 hours lapses to ensure continuing the program. * Yes No My Name * Today's Date * reCAPTCHA If you are human, leave this field blank. Submit Application Hits: 1074