Tribe Recovery Homes Application
First Name: Client first name
Middle Name: Client middle name
Last Name: Client last name
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
Are you on Probation/Parole?
If yes, please provide location:
Officer Phone Number:
Officer Email Address:
Who would be financially resposible for your Program Fees.
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 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.