*Tribe Recovery Homes Application

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:


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?



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 Inc 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