Apply for the Program • Start Your Path Forward

First Name

Last Name

Phone Number

Birth Date

I Identify As

Do you identify as a person with a disability?

Emergency Contact

Name of Contact

Relationship

Contact Number

Income Source

Do you have any sex related charges, convictions, or on the register?

Yes No

Name of Lawyer

Lawyer Contact Information

Do you grant Foundation of Hope permission to speak to your legal counsel on your behalf?

Yes No

Areas of Concern Additional Information

Previous Addictions Treatment History

Other Treatment history

Education

Secondary School Post-Secondary Education Tade/Professional Program

Please list any Health Conditions

Please List Current Medications

Final Thoughts

Is their something that you would like us to know about yourself?

Admission Disclaimer

I, have been made aware of, and indicated my understanding and agreement with, the preceding conditions of participation and associated waivers of liability with Foundation of Hope programs, services, activities, and residences. I further agree to follow all rules, regulations, and conditions, as may be amended from time to time, associated with my participation in Foundation of Hope programs, activities, services, as well as those of Foundation of Hope Residences in effect at the time of my residence. I am aware that if I fail to follow any of the conditions contained in this Admission Package and as may be amended from time to time and/or provided subsequently to my admission, including but not limited to the possession, use, provision for use by another, or sale of any drug and/or alcohol (excluding prescription medication when used as prescribed by the person to whom it is prescribed) at or on any Foundation of Hope Residence, property, program, and/or activity my participation and/or residence with Foundation of Hope will be terminated and I will be immediately and peaceably removed from the property and/or residence.

By printing my name below I consent that this is my electronic signature.

Name

Date

Program Application