House Rules & Conditions (Acknowledgement Section)

Initials Text fieldI will submit this pass request at least 48 hours in advance and will be for no more than 48 hours. I understand that a maximum of 2 separate overnight per 30 days with a minimum of 5 days in between. New residents to the home must remain in the home overnight for a minimum of 14 days.

Initials Text fieldI the resident agree to return at the approved time or risk losing future pass privileges.

Initials Text field I agree to remain sober during the entire pass.

Initials Text field I understand Random UA/BA testing may occur upon return at my own expense ($10.00 per urine test).  

Initials Text fieldI agree to maintain maintain daily communication via text to house group chat.

Initials Text field I understand no new overnight pass can be approved until the previous one is completed and reviewed.

Initials Text field I understand that failure to comply with overnight pass policies may result in loss of privileges, a mandatory check-in meeting and up to discharge from the sober living program.

Name of requester Client first nameClient middle nameClient last name

Departer Date Date Departure TimeText field

Return Date Date Return Time Text field

Full Address where you will be staying Paragraph

Name of person you are staying with Text field

Relationship to person you are staying with Text field

Emergency Contact for this period of time

Name Text field

Phone Text field

Transportation Plan: How do you plan to travel there? Dropdown

I Client first nameClient middle nameClient last name commit to remaining sober and completing daily check ins to the house manager affirming my sobriety.

I affirm that all above is true and commit to remaining sober during my leave with my signature below.

Resident Signature

Signature

Date of signature

Date