Addicts Victorious Online Registration You may also register by calling 217-223-1388 or email us at raymond@horizonsquincy.com. "*" indicates required fields 1Personal Information2Demographic Info3Household Info4Addiction Info5Lodging & Payment Program Date Requested* MM slash DD slash YYYY Select the program start date.Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP What County do you live in ?* Best Phone #*Best Email Address Emergency Contact InformationName of Emergency Contact Relationship to Contact Best Phone # for Contact What is Your Birthdate ?* Month Day Year Gender Male Female Prefer not to answer Marital StatusSingleMarriedDivorcedSeparatedWidow/WidowerRace White Black/African American American Indian/Alaska Native Asian/Pacific Islander Other Education Some High School High School Graduate GED Vocational/Technical School 2YR Degree 4YR Degree Graduate Degree Doctorate Degree Please select all that apply.Employment StatusFull-timePart-timeHomemakerStudentUnemployed-Temporary/SeasonalUnemployed-Long TermEmployer Are you a veteran ? Yes No Dates of Service HousingOwnRent/LeaseGroup QuarterHomelessOtherHousehold Size123456 or moreHousehold Annual Income - All SourcesLee that $10,000$10,000 - $14,000$15,000 - $24,999$25,000 - $34,999$35,000 - $49,999$50,000 - $74,999$75,000 - $99,000$100K - $149K$150K - $199K$200K + Addiction Problems to AddressHow did you hear about Addicts Victorious ? Home Church Do you need a Hotel room ? Yes No Smoking/non-smoking room ? Smoking Non-smoking When do you need to check in ? Sunday Night Monday Morning Payment/Financial InformationNo payment is required at this time. We will contact you with payment details after filling out the information below.How do you intend to pay for the program ?Credit/Debit CardCheckI am requesting financial assistanceIf you require financial assistance, please select that option and we will contact you to work out the details.Amount you could pay PhoneThis field is for validation purposes and should be left unchanged.
