Application for Residency

Have you ever been convicted of a sexual offense?

Yes No

If yes, please provide county and PO name:

Are you enrolled in the Recovery Works program?

Yes No

If female, are you pregnant?

Yes No

If yes, what is the due date?

Date

Relationship status:

Single Married Separated/Divorced In a relationship

Name of partner:

Is your partner clean and sober?

Yes No

Do you have children?

Yes No

If yes, how many?

Ages?

Who are they currently living with?

With family/friends Adopted out Open DCS case

If you are currently separated from your minor children, will you be having visitations?

Yes No

If yes, how often?

Contact Name #1

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Relationship

Phone Number

Area Code Phone Number

Contact Name #2

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Relationship

Phone Number

Area Code Phone Number

Contact Name #3

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Relationship

Phone Number

Area Code Phone Number

Are you a veteran?

Yes No

Do you have anything else you would like to tell us?

By hitting the submit you agree to allow the staff of The Avenues Program to discuss my background and treatment with other professionals and agencies. I understand for the protection of myself and others there may be a need for the Board of Directors or the staff of The Avenues to check my legal standing and criminal background. I also understand that I am giving permission for the staff of The Avenues to contact any and/or all names and facilities on this application. I have read all the questions and answered them honestly. I agree to not use non-prescribed drugs, consume alcohol or violate the law while living at The Avenues. I agree to maintain gainful employment. I agree to stay current with my service fees. I agree to attend all required meetings and classes. I agree to participate in weekly house meetings and share regular house chores. I agree to these conditions because recovery from drug abd/or alcohol addiction is important to me.

Signature *

Clear

Application for Residency

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