New Life Launch Pad - Structured LIving - Continuing Care
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New Life Launch Pad
Contact Information

Please contact Andy Mann:
phone: (910)470-4954
fax: (910) 343-3357
e-mail: andy@newlifelaunchpad.com

Applying for Admission

Please see the admission page for information about, and criteria for, admission. Alternative application methods are given there as well.

Apply for Admission
Name:
Email:
Phone:
Date of Birth:
SSN:
Closest Relative:
Relative's phone:
Currently residing at:
Date you will arrive, if accepted:
Have you lived in a Launch Pad before:
Drivers' license or ID card number:
Prison - where, when, why?:
Nature of handicaps or disability:
Current medications:
Drug(s) of choice:
Length of 12 Step involvements:
Scheduled Court Dates:
Have you had sex crime convictions?:
Kind of employment you have or want?: