Become a Mission Client Today: Royal Pines

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Applicant Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Main Phone:*

Alternate Phone:

Last Address:

Street Address City State ZIP Code

Email Address:*

*This email will be used for general contact needs and is where you will receive a copy of your completed application as well as any necessary follow-up information.

Enter Email Confirm Email

Emergency Contact Information:

Contact Person:*

Relationship:

Phone Number:*

Address

Street Address City State ZIP Code

Additional Information:

Are you an alcoholic?

Yes

No

Are you a drug addict?

Yes

No

Do you have any warrants?

Yes

No

Have you ever been charged with a sexual offense or are you a registered sex offender?

Yes

No

Have you ever been charged with, or convicted of, a violent crime?

Yes

No

CLIENT POLICY AGREEMENT:

Client's Full Name:*

Consent*

72-Hour Abstinence Agreement

Royal Pines 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 and Royal Pines are 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.

Policies

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 Royal Pines and the Jimmie Hale Mission for any medical liability during my residence. I also acknowledge that typing my name into the space below (when applicable) will serve as my digital signature for this form.

Consent for Information to be used in Media Coverage Related to Jimmie Hale Mission

I hereby give permission for Jimmie Hale Mission to use information, photographs, video, etc. gained from my participation in Jimmie Hale Mission programs or activities and any interviews that I give in public announcements in the form of social media, radio, television, publications and all other public relations means or events.

RELEASE AND INDEMNIFICATION

I hereby release and agree to indemnify and hold the Jimmie Hale Mission and all of its employees harmless from and against all claims, demands, payments, suits, actions, recoveries and judgments including attorney’s fee of every nature and description, brought, recovered or arising out of any act or omission of the client, or arising out of the above items.

I agree to all of the above by checking this box and signing below.

Signature*

Date:*

BACKGROUND REQUEST FORM:

Client's Full Name:*

I authorize Royal Pines to conduct an independent investigation of my driving record (MVR), background, police 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 Royal Pines 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 Royal Pines 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:

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

Social Security Number:*

Date of Birth*

Driver's License Number:*

State of Issue:*

State

Signature*

I understand that typing my name in the space provided below (when applicable) will serve as my digital signature for this form.

Date:*

CLIENT CONSENT FOR DISCLOSURE OF RECORDS & INFORMATION

I understand that my records are protected under the Federal Confidentiality Regulations (42 CFR, Part 2) and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (i.e. probation, parole, etc.) and that in any event this consent expires automatically upon my program graduation, discharge or departure unless otherwise specified below.

Disclosure contact

I authorize the staff at the Jimmie Hale Mission to disclose and/or receive information to/from:

Disclosure Purpose

regarding the following information: my attendance and compliance at Royal Pines. The purpose of the disclosure authorized herein is to:

Phone

Email

Start Date

End Date

Client Signature*

Date*

Witness Signature*

Date*

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.

AGREEMENT:*

YOU CAN BRING:
Bible (study), personal hygiene products, towels and washcloths (2), underwear (5), socks (5), shower shoes (1 pair), casual shoes (2 pair) or tennis shoes, classroom clothes — pants (7 pairs) no jeans with holes — shirts (12) — shorts (2), sleepwear — pajamas or sweatpants, belt (must be worn at all times), notebooks, pens, pencils. NO luggage.

OPTIONAL:

Alarm clock (no radio), tobacco products, clothes hangers.

POLICIES

All medical, legal or personal appointments must be approved by the Director prior to scheduling the appointment. (Clients are responsible for providing their own transportation to and from said appointments.)

Note: Clients are asked to wear shirts with collars for both classroom 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. Shorts can be worn after 5:30pm M-F.

Clients and their belongings are subject to search upon entry to the Jimmie Hale Mission. 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) daily.

All cell phones will be collected at intake and returned after graduation.

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.<

I agree that I have read and understand the above information regarding items and policies.

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Client Application

Royal Pines

Royal Pines Client Application

Applicant Information:

Emergency Contact Information:

Additional Information:

Health Information:

NOTICE:

CLIENT POLICY AGREEMENT:

BACKGROUND REQUEST FORM:

7-year Address History:

CLIENT CONSENT FOR DISCLOSURE OF RECORDS & INFORMATION

ITEMS TO BRING & FACILITY POLICIES

Shepura

Jessie's Place

Royal Pines