Name: Jimmie Hale Mission
Address: P.O. Box 10472, Birmingham, AL, 35202, US
Telephone: (205) 323-5878

PLEASE NOTE: All incoming clients are required to take a COVID-19 test before entering the program. We are more than willing to assist you in the process if needed. Please call us at 205-324-2271 if you have any questions about testing.

JHM Client Application

Step 1 of 6

CLIENT POLICY AGREEMENT:
Client's Full Name:*
72-HOUR ABSTINENCE AGREEMENT: The Jimmie Hale Mission does not provide detoxification services, and as such, incoming residents must refrain from the use of alcohol or any other psychoactive substance that causes withdrawal for 72-hours prior to admission. New residents who exhibit withdrawal symptoms will be evaluated by our staff for possible referral to a hospital’s detoxification services. If detoxification services are considered necessary, clients are responsible for the medical cost. If medical services are refused, you may be denied admission to the recovery program.
SPORTS & ACTIVITY RELEASE: The Jimmie Hale Mission is hereby released from any liability due to injury for any sports or leisure activity. You must take full responsibility for any accident or personal injury caused by your participation.
By signing below, I acknowledge all rules, policies and liabilities have been read and explained to me, and I am fully committed to comply with each of them. Furthermore, I affirm that I will not use alcohol or any psychoactive substance for 72-hours prior to my admission into the program, and I do hereby release the Jimmie Hale Mission for any medical liability during my residence. I also acknowledge that typing my name into the space below will serve as my digital signature for this form.
Applicant Signature:*
Date:*
Date Format: MM slash DD slash YYYY

BACKGROUND REQUEST FORM:
Applicant's Full Name:*
I, [the above typed name], authorize the Jimmie Hale Mission to conduct an independent investigation of my driving record (MVR), background, police record and criminal history record information pertaining to me, which may be in any state or local criminal justice agency in the United States, and all public records for the purpose of confirming the information provided to the shelter.
I release the Jimmie Hale Mission and/or its agents and any person or entity that provides information pursuant to this authorization from any and all liabilities, claims, or law suits in regards to the information obtained from any and all of the above referenced sources used. I further understand that the Jimmie Hale Mission and its agents will adhere to applicable state and federal statutes concerning the securing of information, handling, and release of the information obtained.
The following is my true and complete legal name. All information on this document is true and correct to the best of my knowledge:
Client's Full Name:*
7-year Address History:
Present Address:*
Street Address City State ZIP Code
How long at this address?*
"X" years or months
Former Address 1:
Street Address City State ZIP Code
How long at this address?
"X" years or months
Former Address 2:
Street Address City State ZIP Code
How long at this address?
"X" years or months
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number:*
Driver's License Number:*
State of Issue:*
State
Client Signature:*
Typing my name in this blank will serve as my digital signature.
Date:*
Date Format: MM slash DD slash YYYY

ITEMS TO BRING & FACILITY POLICIES
You will get a copy of this information in your email confirmation as well as an option to downloaded the from immediately after submitting the application.
MANDATORY ITEMS: Bible (study), personal hygiene products, towels and washcloths (1 week supply), underwear, socks, shower shoes, casual shoes (1 pair), work shoes or boots (1 pair), classroom clothes, work clothes, a belt (must be worn at all times), and notebooks, pens and pencils. NO jogging pants and NO luggage allowed.
OPTIONAL ITEMS: Alarm clock (no radio), tobacco products (2-week supply), and clothes hangers.
All medical, legal or personal appointments must be approved by the Director prior to appointment. (Clients are responsible for providing their own transportation to and from said appointments.)
Note: Clients are required to wear shirts with collars for both class-room and church dress. Shorts are only permitted during outside recreation. Shorts are not permitted for any work detail or classroom activities. Bring enough clothes to last for at least two weeks. Client’s laundry will be done weekly.
Clients and their belongings are subject to search upon entry to Royal Pines . In the event any addictive substance is found during the search this evidence will be used for prosecution.
All medication must be relinquished to a staff member upon entry. Clients will be given access to their medication (both prescription and OTC) dailye.
Clients are allowed to have cash (for drink machines).
Medication: FDA scheduled drugs are NOT allowed. Please ask your doctor to prescribe medications which are listed on our “Acceptable Medication List.” All OTC and prescription medications MUST be turned in to office upon arrival.
Legal Issues: If you have any legal issues such as probation, parole, and/or court dates please have all contact information and dates with you upon arrival. You will need to provide names, phone and fax numbers, and email information so we can properly inform each agency. Legal backgrounds are checked before entering the program. If you have any outstanding misdemeanor or felony warrants you will not be allowed to enter the program. These legal matters must be taken care of before admittance. In addition, any persons with a history of sexual or violent crimes cannot be accepted.
Detoxification: If you are withdrawing from alcohol, benzodiazepines, or barbiturates you are required to bring proof of medical detoxification before you can enter the program at the Jimmie Hale Mission.
AGREEMENT:*
I agree that I have read and understand the above information regarding items and policies.

Please Note: Some applicants may require a "Consent for Disclosure of Records & Information" form following the submission of this application. A link for this request will be provided in the confirmation window following submission, and in the verification email. If you do not require this information to be sent, simply ignore this option.
Consent*
I have read and understand the above notice.
Clicking the submit button below will complete the application process.
PLEASE NOTE: Once you click "Submit" the information will be compiled and implemented in a compressed form. Depending on the amount of data entered and your connection speed, this process may take time to complete. Please do NOT hit the back button OR refresh the page until you see the confirmation screen as this could prevent the form from being submitted properly. Thank you.

JHM Client Application

Step 1 of 6

Applicant Information:

Emergency Contact Information:

Additional Information:

Health Information:

NOTICE:

DISCLAIMER:

CLIENT POLICY AGREEMENT:

BACKGROUND REQUEST FORM:

7-year Address History:

ITEMS TO BRING & FACILITY POLICIES