Second Chance Recovery Inc.  - Helping to restore lives one day at a time.
Application for Addission
 
  1. Fill out application. Be sure to complte application as thorough as possible. Full name and expected move in date are very important!
  2. Fax application to ( 941) 257-8414, Mail to Second Chance Recovery Inc. PO Box 380594 Murdock, Fl. 33938-0594 or email it to onedayatatime@secondchancerecovery.net/mail
  3. Executive director will contact client and/or Treatment Center to arrange a phone or personal interview.
  4. Interview
  5. Upon approval, an acceptace letter and/or phone call will be sent to the client and the treatment center.
 
       Welcome to Second Chnce Recovery Homes:
 
   Name__________________________________ Age_____ DOB__________
   Have you ever applied or lived at Second Chnace Recovery Homes? Y___N___
   Current Address_________________________________________________
   City__________________State________________Zip Code_____________
   Home Phone______________________Cell Phone_____________________
   Work Phone_______________Email Address__________________________
   Social Security #___________________Birth Place______________________
   Height_______Weight_______Hair Color______Eye Color______Race______
   Distinguishing Marks ( scars, tattoos, etc.)______________________________
   In Case of emergency Notify________________________________________
   Phone # (____)__________________Relationship______________________
   Marital Status____________________Do You Have Children? Y____N_____
   Parents Name____________________ Address________________________
   Phone # (_____) _________________Cell Phone# (____)________________
   Are you currently on probation? Yes____ No_____ Where?_______________
   Probation officers name____________________ Phone #(___)_____________
   Are you on community control probation? Yes_____ No_______
   What is your current offense? _______________________________________
   If currently residing outsideFL. or have lived in states other than FL., a criminal background Check(s) for those states must be submitted with this application.
  
   Have you ever commited/been chrged with arson?  Yes_____ No_____
   Have you ever been charged with cruelty to animals?  Yes____ No____
   Have you ever been charged/convicted of a violent crime Yes____ No____
   Have you ever been charged/commited with a sexual crime? Yes___No___
   Do you have the funds to cover entrance fee? Yes___ No___
   Do you have legal idetification? Yes___ No___
   Do you currently have a job? Yes___ No___ Full/part time ( circle one)
   Name of company.________________Supervisors name_________________
   Phone# (___)________________How long employed there?______________
   Do you have a valid drivers license? Yes___No___
   If yes what is the Driver's License # and state issued______________________
   Do you own your own vehicle? Yes___No___
   If yes what is the name o your insurance agency?_________________________
   Policy#____________________Expiration date_________________________
   If for some reason, you cannot pay $100.00 a week, who will you call to help?
   Name_______________________Phone# (____)______________________
   Do you receive any ongoing finacial reimbursments for any reason? (such as, SSI,Disability,Medicaid, Trust Fund, etc.)  Yes___No___
    If yes explain. __________________________________________________
 
       Addition information will be required upon approval and placement in one of our homes. We look forward to meeting you and working with you on your road to recovery.