Sober Living Facility Curfew Extension Pass

Your Name: Client first nameClient last name

Your Phone Number: Client phone

Curfew Extension Details:

Date of Request: Date

Original Curfew Time: 10 pm

Extended Curfew Time Requested:

Text field pm

Reason for Curfew Extension:

Text field

Address of Destination:

Text field

Contact Person at Destination:

Text field

Contact Number:

Text field

Expected Return Time:

Text field pm

 *If you are not meeting program requirements your request will automatically be denied*

*Any delay of the approved curfew will result in a standout until a clean UA is received. *

 Client Signature

Signature

Date of request: Date