Application for Addission
- Fill out application. Be sure to complte application as thorough as possible. Full name and expected move in date are very important!
- Fax application to ( 941) 257-8414, Mail to Second Chance Recovery Inc. PO Box 380594 Murdock, Fl. 33938-0594 or email it to email@example.com/mail
- Executive director will contact client and/or Treatment Center to arrange a phone or personal interview.
- 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___
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?_________________________
If for some reason, you cannot pay $100.00 a week, who will you call to help?
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.