C3 A New Life, LLC
Application
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Are you ready to make a change?
Radio buttons
Has your life become unmanageable?
Radio buttons
Are you ready to live a sober lifestyle?
Radio buttons
Full Name: Client first nameClient last name
Like to be called: Text field
Address:Client AddressClient CityClient StateClient Zip
Email:Client email
Phone:Client phone Type: Dropdown
Date of Birth:Client birthdate
Do you have any pending charges?
Radio buttons
If so, what are your charges? Paragraph
Are you a convicted Felon?
Radio buttons
Charged with? Paragraph
Are you on Probation/Parole?
Radio buttons
Officer's Name: Text field Phone # Text field
Email Text field
Can you pass a drug/alcohol screen?
Radio buttons
If not, what substance(s) would show up? Paragraph
What is your sober date? RecoveryHistory
Are you currently employed?
Radio buttons
What Company? Text field Phone Text field
Address of Company: Paragraph
Emergency Contact: Text field
Emergency Contact Phone: Text field
Emergency Contact email: Text field
Other people we can disclose information regarding your recovery?
1 - NAME: Text field
PHONE Text field EMAIL Text field
2 - NAME: Text field
PHONE Text field EMAIL Text field
3 - NAME: Text field
PHONE Text field EMAIL Text field
4 - NAME: Text field
PHONE Text field EMAIL Text field
Are you currently in a relationship?
Radio buttons
If so, Name of partner? Text field
Phone number of partner? Text field
I agree C3 A New Life, LLC can lawfully contact any names you have mentioned above including your Parole/Probation officer, partner/significant other, emergency contact and/or others regarding your participation, attendance, willingness to comply and how you're doing in regards to your recovery?
Radio buttons
Signature
FORMS OF IDENTIFICATION:
Do you currently have a valid Driver's License or state ID? Dropdown
ID or License# Text field State Text field
Expiration Date: Date
Do you have a valid SS card? Dropdown
ID#Text field
Do you have a valid Passport? Dropdown
ID# Text field
Expiration Date: Date
Do you have a birth certificate? Dropdown
Are you currently eligible to work in the United States?
Radio buttons
What medications are you currently taking? Paragraph
Are you willing to give up medications not deemed appropriate by C3?
Radio buttons
I am fully aware of the program rules, standards, what is expected of me, program fees and fines and my living situation, This is a voluntary application for me to live sober at C3 “A New Life”
Signed Signature Date: Date
RESPONSIBLE PARTY
Please choose one:
OPTION 1: I am fully responsible and capable for paying all of my program dues/fees charged and disclosed to me at signing to enter the program. Furthermore, I agree to pay reasonable attorney fees on behalf of C3 if needed to collect any unpaid balance I owe if I leave the program willingly or unwillingly.
OPTION 2: Someone else will be paying my fees and accepts to be the responsible party for any fees and dues associated to my admittance. The responsible party must sign, provide 2 forms of acceptable documentation per IRS tax form guidelines and fill out the form below in order for you to complete the intake process. If you can not afford to pay your fees and support your personal living expenses you will not be able to enter the program. The responsible party agrees to pay any reasonable attorney fees for C3 to collect any unpaid debt on behalf of me.
Checkboxes
Responsible Party Name: Text field Relationship Dropdown
Date: Date
Signature
Responsible Party Forms of ID if NOT SELF PAY
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
1st Type of ID Text field Expiration Date Date
Initial Copy given Initials Text field
2nd Type of ID Text field Expiration Date Date
Initial Copy given Initials Text field
Address of Responsible Party: Paragraph
Responsible Party Phone# Text field Email: Text field
Date: Date
Responsible Party Signature: Signature