NAME: Resident first name Resident last name  DATE OF BIRTH:Resident birthdate

DRIVERS LICENSE: Text field STATE: Text field

PHONE#:Resident phone EMAIL: Resident email (required)

EMERGENCY CONTACT: Contact 1 name RELATIONSHIP:Contact 1 type

ADDRESS: Text field

CONTACT PHONE#:Contact 1 phone
CONTACT EMAIL: Contact 1 email

 

MEDICAL INFORMATION
How long have you been sober? Resident sobriety date

Drug(s) of Choice:Resident substance of choice

Which meetings do you attend? (AA, NA, CA, SMART Recovery, Refuge, Faith, etc.) Text field

Sponsor Name and Phone# (If Applicable): Contact 2 name Contact 2 phone

List any medical conditions:Resident diagnosis

WHAT IS YOUR PASSION? Text field

DO YOU HAVE A HOBBIE OR INTEREST? Text field 

List any prescription medications: 

Medication #1

Medication: Medication 1 name Dosage: Medication 1 dosage

Quantity: Medication 1 quantity Category: Medication 1 category

Frequency: Medication 1 frequency MD: Medication 1 md

Notes: Medication 1 notes

Medication #2

Medication: Medication 2 name Dosage: Medication 2 dosage

Quantity: Medication 2 quantity Category: Medication 2 category

Frequency: Medication 2 frequency MD: Medication 2 md

Notes: Medication 2 notes

Medication #3

Medication: Medication 3 name Dosage: Medication 3 dosage

Quantity: Medication 3 quantity Category: Medication 3 category

Frequency: Medication 3 frequency MD: Medication 3 md

Notes: Medication 3 notes

 More Medications can be added via the Client Page.

 

 

IMPORTANT NOTICE: CFC LOUD N CLEAR FOUNDATION RECOVERY HOUSES (B-HOUSES)  reserves the right for expulsion, without prior notice or refund of deposit and fees, of any resident member who is found to be: 1) using alcohol or drugs; 2) engaging in disruptive behavior; or 3) in default of payment of weekly membership fee. All residents of  CFC Loud N Clear Foundation B-House are members of our recovery home and program. You do NOT have renter’s rights or any rights of tenants pursuant to the New Jersey Property Code, and expressly waive any such rights in exchange for membership privileges.

I have read the above notice and understand that I am applying for membership of CFC Loud N Clear Foundation B-House as a member of a recovery home and program. I agree to abide by the responsibilities and requirements of the house and fully subject myself to the rules of the home, which include periodic/random drug testing. I understand that I am subject to immediate expulsion from the home if any of the following occur: 1) I use alcohol or drugs (other than prescribed medication); 2) I engage in disruptive behavior (continued patterns of irresponsible behavior are considered disruptive behavior); 3) I fail to pay my weekly residency fee. I understand that my deposit and member fees will be forfeited if I have been expelled from the CFC Loud N Clear FOundation B-House unless I leave voluntarily and at least 30 days notice is given.

By signing below, I certify that the information contained in this application is true. I have read and understand the B-House house rules and policies. I understand and accept the above conditions set forth for membership to B-House and agree to abide by said conditions should I be selected as a member resident.

 

SIGNATURE OF APPLICANT: Signature

DATE: Date

 

The membership application was reviewed with the applicant and he/she acknowledged the IMPORTANT NOTICE and requirements for membership in CFC Loud N Clear Foundation B-House set forth above. The applicant has reviewed the B-House house rules.

 

SIGNATURE OF HOUSE MANAGER: Signature

DATE:Date

 

I have received a copy of the house rules and policies. I understand that failure to follow the rules and/or responsibilities in monetary fines and/or expulsion from CFC Loud N Clear Foundation B-House. In the event of expulsion, I understand that any fees/deposits paid to the house will be forfeited.

 

NAME OF RESIDENT MEMBER: Text field

 

SIGNATURE: Signature

DATE: Date