Hope Manor Agreement & Application
Please read the following, and signify agreement by selecting AGREE. Type your name at the bottom to state that this is completely accurate and honest.
Sign in to Google to save your progress. Learn more
Email *
I understand that if the application is not accurate I may be asked to leave Hope Manor immediately and without refund. *
The above listed rules were explained to me and I understand them. *
I understand that I am a guest at Hope Manor. *
I agree to follow these rules during my stay at Hope Manor. *
I understand that my continued stay at Hope Manor is contingent upon completion of my 30 day probationary period. *
I understand that I must be able and capable to care for myself, comply with daily house requirements, and find employment without the need for supervision.   *
In consideration of the permission granted me to stay temporarily as a guest in Hope Manor, I promise and agree to observe and abide by all of the rules, regulations and requirements stated above and any further rules that the management may need to include for the smooth running of the facilities. *
I promise and agree to peacefully leave the premises at any time that I drink any alcoholic beverages, use any mind-altering chemicals, violate any of the above-mentioned rules or whenever requested to do so by management.   *
I understand that I will be required to remain drug and alcohol free while living at Hope Manor. *
I agree to submit to a urine and breath test at any time and that refusal will result in my immediate discharge, and agree to leave Hope Manor if a positive result comes up. *
I agree to waive and relinquish any and all claims and demands for damages which may or might arise in any way and from any cause, whether from personal treatment or any patent/latent defect in the premises or other direct or implied negligence, regardless of the nature and the occasion thereof. *
I am not under the influence of any non-prescribed mind or mood altering substances at this time and I understand what I am signing. *
I understand that Hope Manor is not responsible for me if I relapse and transportation from the house is my responsibility.  I understand that Hope Manor will only take me to the homeless shelter upon relapse. *
I agree to waive my right to any and all eviction procedures and will leave at Hope Manor’s request. *
Type your name in agreement to these statements:
Date:
MM
/
DD
/
YYYY
First Name *
Last Name *
Address:
Address:
State:
Zip:
Phone Number:
Date of Birth:
MM
/
DD
/
YYYY
Social Security Number:
Gender
Clear selection
Desired Entry Date:
Planned Exit Date (9 months recommended):
Race:
How did you Learn About Hope Manor:
Emergency Contact/Relative:
Emergency Contact Phone Number:
How long have you been using alcohol and/or drugs?
How do you identify yourself?
List ALL the drugs that you have used in the past 3 years:
What was the last drug used and when:
(This information will be used to determine urinalysis in the future, so be 100% honest.)
History of Seizures:
(This information will be used to determine urinalysis in the future, so be 100% honest.)
Sobriety Date (the date of first day 100% without drugs or alcohol)
MM
/
DD
/
YYYY
Probation Officer:
Probation Officer Phone Number:
Attorney:
Attorney Phone Number:
AA / NA Sponsor:
AA / NA Sponsor phone:
Counselor:
Counselor Phone:
Doctor:
Doctor Phone:
Marital Status:
Clear selection
Prior treatment facilities or centers:
Criminal Record:
Do you have ANY mental health issues or diagnosis?
Clear selection
If yes, what:
Do you have ANY physical health/medical issues or disabilities?
Clear selection
If yes, what:
Have you been prescribed any medication within 6 months:
Clear selection
If yes, list all:
List ALL medication you are currently taking and LAST date taken:
Are you required to register for ANY purpose?
Clear selection
If yes, explain:
Are there any Restraining Orders against you or by you?
Clear selection
Who:
Relationship:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms