Tribe Recovery Homes Application

 

Applicant Information:

First Name: Client first name

Middle Name: Client middle name

Last Name: Client last name

Birthdate: Date

Gender: Client gender

Phone Number: Client phone

Email: Client email

 

Employment: (If none, please type "None")

Employer: Employer 1 name

Position: Employment 1 position

 

Insurance: (If none, please type "None")

Insurance provider: Text field

Group ID: Text field

 

Legal Situation:

 Paragraph

Are you on Probation/Parole?

Radio buttons

If yes, please provide location:

Text field

Officer name:

Text field

Officer Phone Number:

Text field

Officer Email Address:

Text field

 

Who would be financially resposible for your Program Fees.

Text field

 

Is there anything else you would like to include?

Paragraph

 

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.

Tribe Recovery Homes performs a CBI Background Check on all potential applicants. This background check is to protect both current program participants and prospective applicants. 

By signing you give permission to Tribe Recovery Homes to run a background check.

This background check does not disqualify you from the program eligibility, nor will the results be disclosed to ANY outside entities.

 

First Name: Client first name

Last Name: Client last name

Date: Date

Signature