RELEASE OF INFORMATION AUTHORIZATION

 

 

I hereby authorize release of information concerning Text field, whose date of birth is Date. I understand that information will be communicated verbally and or in written form. Information concerning psychiatric, psychological, medical diagnosis, drug or alcohol abuse, economic status, and educational information will be released and/or communicated if indicated below. I authorize the following information to be released to Rise and Shine Foundation

 

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I acknowledge that all information I authorize to be released or requested will be held strictly confidential. I understand this authorization will expire one (1) year after the date signed.

 

 

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 Client Signature:

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PROGRAM PARTICIPANT PERSONAL PROPERTY WAIVER OF LIABILITY:

 

I agree to accept full responsibility for any personal property I have been advised to not bring any item of sentimental or significant monetary value into Rise And Shine Transitional Living Home because of risk of loss or theft.

I agree to hold the Rise And Shine Transitional Living Home staff harmless or responsible in any way, shape, form and/or fashion, from any and all losses I may have, from theft or otherwise.  I understand that my belongings are not insured unless I obtain my own insurance policy at my own cost.

Upon leaving, Rise And Shine Transitional Living Home for any reason whatsoever, I will immediately remove my personal belongings.  All personal belongings left behind after three (3) days, will be donated without compensation.

Client Signature: 

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Licensee Agreement

Initials Text field I understand that THIS AGREEMENT IS NOT A LEASE.
Initials Text field I understand that Rise and Shine Foundation provides and pays for Utilities, furnishings, cleaning
services and controls all keys to the premises and individual rooms
Initials Text field I understand that if I violate any rules of the licensee agreement, I may be considered a criminal
trespasser and subject to arrest under State Penal Code, “Criminal Trespass”
Initials Text field I understand that rooming homes and innkeepers have broad authority to lien all property contained
within the rented room.
Initials Text field I have read and understand the house rules provided to me
Initials Text field I understand that in order to qualify I must have supplemental income and establish a 3rd party payee
company if necessary.
Initials Text field I understand that Rise and Shine is NOT an assisted living facility or a nursing home and that LANDLORD
& PROPERTY MANAGER DOES NOT provide assistance with activities of daily living, medicine management,
bathing, brushing, shaving, cutting food, toileting, transportation, supervision outside of the residence,
incontinence care, dressing, movement or other daily activities. Outsourced 3rd parties may stop by and provide
these services to the “licensee” if the “licensee” has a relationship with this outsourced 3rd party, however under
no circumstances does RISE AND SHINE provide these services directly.
Initials Text field I understand that any damages (other than normal wear) will be my financial responsibility
Initials Text field I understand that rooming home operator will have a lien for unpaid rent against all of Licensee's
nonexempt personal property that is in the Property and may seize such nonexempt property if Licensee fails to
pay rent. Property Code governs the rights and obligations of the parties regarding Landlord's lien. Landlord may
collect a charge for packing, removing, or storing property seized in addition to any other amounts Landlord is
entitled to receive. Landlord may sell or dispose of any seized property in accordance with the provisions of the
Property Code.
Initials Text field Any person who is a prevailing party in any legal proceeding brought under or related to the transaction
described in this lease is entitled to recover a maximum of $500 attorney’s fees from the non-prevailing party.

I.FEES
Initials Text field The licensee, licensee’s representative and/or licensee’s legal representative agree that the Resident (or
other specified party) will pay the basic rate as of the date of this agreement, which is $725 per month or $25 Per
day per shared room, and non-refundable registration fee $300.00.
Initials Text field Payment is due the 1st - 4th of each month depending on the date that the licensee receives their income.
Initials Text field Licensee must set up 3rd party as Payee for supplemental income

II. RESPONSIBILITIES OF LICENSEE, LICENSEE’S REPRESENTATIVE AND/OR LEGAL REPRESENTATIVE

A. You, your representative and/or legal representative, to the extent specified in this agreement, are responsible for the following:
1. Payment of the monthly fees
2. Supply of personal clothing, activities of daily living, medicine, medicine management and other normal day-to-day items and tasks including but not limited to doctor visits,
transportation, case management and social worker appointment meetings and scheduling’s.
3. Payment must be sent to Company Cash app, Company preferred payment authorization method or through 3rd party payee

III. PROPERTY MAINTENANCE
A. Licensee’s General Responsibilities: Licensee, at Licensee’s expense, must:
(1) Keep the Property clean and sanitary;
(2) Promptly dispose of all garbage in appropriate receptacles;
(3) Take action to promptly eliminate any dangerous condition on the Property and/or room;
(4) Certify that they will perform all activities of daily living without the help or assistance of any RISE
AND SHINE representative such as showering, taking medications, shaving, cutting and preparing food, toileting, transportation, dressing and any other activity performed on a daily basis.
(5) Certify that they have inspected their room and that the room is clean and well-maintained.
Initials Text field (Initial on line to left to certify the above paragraphs regarding pest control and infestation)

IV. WAIVER OF LIABILITY
Initials Text field Each party hereby agrees to waive liability of Rise And Shine Inc. as an organization, its administrative
staff, or any program support service provider from any liability due to personal physical or mental injury, while
staying at the Men’s/ Woman's House. This pertains to any injury while on the property, or while being
transported in any organizational or staff personal vehicle.
Initials Text field It is my intention and I understand that I am binding myself, my heirs, agents, relatives, executors,
administrators, assigns and successors in interest, and understanding this, so hereby expressly release and
discharge RISE AND SHINE, its agents, owners, landlords, directors executives, successors, administrators, assigns,
affiliates and agents from any claims against RISE AND SHINE created or arising out of, or in any way whatsoever
related to the service or housing space provided. I hereby waive any claim for damages to persons or property,
which may occur as the result of the use of the said premises. This waiver includes any negligent acts or omissions
caused directly or in-directly by RISE AND SHINE Cooperative Living or the owners of said Property, including its
officers, directors, or employees and understand that my claims, which may in the future arise out of personal
injuries, accident, death, hurricanes, tornadoes, rain, fire or other acts of God to the residence, myself or damage
to my property of any kind, are hereby waived.
Initials Text field I, and any and all family, relatives, attorneys, assignees and any others acting on my behalf hereby further
agree to waive liability and hold harmless RISE AND SHINE Cooperative Living, its owners, representatives, agents
or Owners of said Property, including its officers, directors, or employees, from any claims or damages, which may
occur to the undersigned licensee or to any child, invitee, or guest of the undersigned.

Initials Text field It is understood and agreed that this agreement includes, but is not limited to, injuries occurring due to:
slipping and falling on any surfaces wet or dry, transportation to and from the premises or any other location, fires,
sprained or broken limbs, cuts, abrasions, eye injuries, bacterial infections, death, fights, riots, stabbings, tornados,
hurricanes, floods, hail storms, acts of terrorism and any other acts of God, accidents or injuries on the property or
off the property.

Initials Text field Each party agrees to waive liability and hold harmless the other party and its employees, members, land-
lord, successors, attorneys, family members, agents and assigns, from any claims, liabilities, losses, damages, and expenses asserted against the other party and arising out of the waive liability ing party’s negligence, willful misconduct, and negligent performance of, or failure to perform, any of its duties or obligations under this
Agreement. The provisions of this indemnification are solely for the benefit of the parties hereto and not intended
to create or grant any rights, contractual or otherwise, to another person or entity.
Initials Text field Licensee will waive liability and hold harmless RISE AND SHINE, its agents, owners, directors and officers
against all liability, including liability arising from death or injury to person or property during the term of this
agreement, and any renewal or extension thereof, caused by any act or omission of the Tenant, or the family,
guests, agents or employees of the Tenant. b) Tenant will waive liability and save Landlord harmless from all
liability, damage or expense incurred by Landlord as a result of death or injury to persons or damage to property
(including the Premises) where this Lease Agreement required the Tenant to procure insurance for said liability,
damage or expense and Tenant failed to do so.
Initials Text field RISE AND SHINE, its agents, owners, directors and officers shall not be liable for any damage or loss to
person or property caused by other licensees or other persons, or caused by theft, vandalism, fire, water,
smoke, explosions or other causes unless the same arises solely from the omission, fault, negligence or other
misconduct of COMPANY. Failure or delay in enforcing Lease covenants of other Tenants shall not be deemed to
be negligence, omission, fault or other misconduct.

V. RULES
Initials Text field I am aware that I maybe fined and or discharged from the property for violation of house
rules/destruction of property
Initials Text field I am required to notify RISE AND SHINE a minimum of thirty days prior to vacating the premises or I will
forfeit my deposit
Initials Text field My payment (in full) is due by no later than the fifth of each month via a third party representative payee
Initials Text field I understand that upon leaving a RISE AND SHINE location by my will or as a result from rule infractions I
will not be eligible for a refund.
Initials Text field I understand that this agreement is not a lease. Licensee holder may give a minimum of 30 day notice to
vacate. Any damages by licensee will be the financial responsibility of the licensee and may be withdrawn from the
refunds. Management of RISE AND SHINE Cooperative Living may terminate this licensee agreement at any time.
Violation of house rules may result in fines or my dismissal from the property. Threats or acts of physical violence
against other licensees or management will result in immediate termination of this license and may result in filing
of criminal charges.
Initials Text field I understand that “vacating” the premises is defined as all of my belongings and myself leaving the property
after returning my key.

Initials Text field I understand that some of the food used is sourced from the community. Licensees are expected to
participate in these resources
Initials Text field RISE AND SHINE Cooperative Living reserves the right to relocate licensees to our other cooperatives at
our discretion. Any costs associated with change of address or inconveniences caused by relocation are the sole
responsibility of the licensee
Initials Text field Management / Staff of RISE AND SHINE Cooperative Living may ask me to provide a urine sample when:
• Erratic or other behavior typical of a person under the influence of alcohol or illegal drugs is
observed
• Drug / Alcohol paraphernalia is found on my or in my possession
• Randomly

Initials Text field Under no circumstances are drugs, alcohol or other “non-prescribed” medication allowed in the property.
I understand that if I have been found to be using or in possession of any of the above items, I will immediately be
in violation of this agreement and will be asked to vacate the unit immediately.

VI. PEST CONTROL AND INFESTATION
Bed bug addendum AND other infestation:
A. This addendum addresses situations related to bed bugs and other infestations (roaches, gnats etc.) which
may be discovered infesting the dwelling or personal property in the dwelling. You (licensee) understand that we
relied on your representations to us in this addendum.
B. INSPECTION. You agree that you:
Have inspected the dwelling prior to move-in and that you did not observe any evidence of bed bugs,
roaches or other infestation
C. INFESTATIONS. Prior to move-in, Licensee is certifying that they have examined the property for bed bugs,
rodents and other bug infestations and did not observe any evidence of bed bugs or bed bug infestation
or any other infestations including roaches, gnats etc. Therefore, in signing this addendum, Licensee
certifies that if bed bugs or other bug infestations are later found in this unit, they will be deemed to have
been introduced by the Licensee or one of the Licensee’s guests and that the LICENSEE (TENANT) WILL BE
RESPONSIBLE FOR THE PEST TREATMENT, including all reasonable costs of cleaning and pest control
treatments. If we must move other residents in order to treat adjoining or neighboring dwellings to your
dwelling unit, you will be liable for payment of any lost rental income and other expenses incurred by us
to relocate the residents. If you fail to pay us for any costs you are liable for, you will be in default, and we
will have the right to terminate your right of occupancy and exercise all rights and remedies under the
lease contract. You will be held directly liable and will deal directly with city officials including but not
limited to section 8 inspectors, code compliance inspectors, police officers and any other party that
deems the unit unclean and infested and will hold landlord/property manager harmless for bed bug,
roach or other pest infestations.
D. COOPERATION. If we confirm the presence or infestation of bed bugs or other bugs or rodents, you must
cooperate and coordinate with us and our pest control agents AT YOUR EXPENSE. You must follow all
directions from us or our agents to clean and treat the dwelling that is infested. You must remove or
destroy personal property that cannot be treated or cleaned as close as possible to the time the dwelling
is treated. We have the right to require you to temporarily vacate the dwelling and remove all furniture,
clothing and personal belongings in order for us to perform pest control AT YOUR EXPENSE. If you fail to
cooperate with us, you will be in default and we will have the right to terminate your right of occupancy
and exercise all rights and remedies under the lease contract. YOU ALSO AGREE TO ALLOW US TO

EXTERMINATE THESE PESTS IMMEDIATELY UPON DETERMINATION THAT INFESTATION HAS OCURRED
AND THAT YOU WILL REIMBURSE US FOR THIS EXTERMINATION.
Initials Text field (Initial on line to left to certify the above paragraphs regarding pest control and infestation)

VII. AGREEMENT AUTHORIZATION
We, the undersigned, have read this Licensee Agreement and agree to abide by the terms and conditions.

   Client Signature:
 Signature