New Life Launch Pad - Structured LIving - Continuing Care
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Contact Information and make your payment
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Please contact-

*phone: (910) 632-2344
*fax: (910) 632-2346
*e-mail: [email protected]

Houses
Launch Pad Guest Name
Payment Description (Enter dates paying for)

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?: