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Application Page

THE HOPE HOUSE FOR OPPORTUNITIES FOR LIVING IN FAITHFUL EXPECTATION

ADOLESCENT RECOVERY CLUBHOUSE

A NON-CLINICAL SUBSTANCE FREE LIFESTYLE DEVELOPMENT CENTER

"IT'S NOT HARD TO MAKE DECISIONS WHEN YOU KNOW WHAT YOUR VALUES ARE"

〰️

"IT'S NOT HARD TO MAKE DECISIONS WHEN YOU KNOW WHAT YOUR VALUES ARE" 〰️

The h2o 4 l.i.f.e.

ADOLESCENT RECOVERY

CLUBHOUSE

Applicant's Name

First Name

Last Name

Date of Birth

Phone

(###)

###

####

School

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Signature of Applicant

Date

YYYY

Signature of Parent or Legal Guardian

Date

YYYY

Client's Name

First Name

Last Name

Legal Guardian

Mother's Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

CLIENT'S STRENGTHS & POSITIVE CHARACTERISTICS

DO YOU LIKE SPORTS?

Yes

Favorite Sport(s)

DO YOU HAVE FRIENDS?

Yes

Favorite things to do with Friends?

IF YOU COULD SPEND A DAY ANYWAY YOU WANTED, WHAT WOULD YOU DO?

IF YOU COULD LEARN SOMETHING NEW, WHAT WOULD IT BE? (example: learn to play guitar)

IF YOU COULD LEARN ABOUT A JOB/CAREER, WHAT WOULD IT BE?

I do

I do not

Exceptions

Client/Parent/Guardian Signature

Date

YYYY

DOES YOUR CHILD HAVE ANY MEDICAL ILLNESS(ES) THAT WE NEED TO BE AWARE OF?

Yes

If your answer is yes, please list your child's illnesses.

Does your child have any allergies? If yes, please list them.

Physician's Name

Phone

(###)

###

####

Parent/Guardian/ Signature

Date

YYYY

h20

Application Page

"IT'S NOT HARD TO MAKE DECISIONS WHEN YOU KNOW WHAT YOUR VALUES ARE"

〰️

"IT'S NOT HARD TO MAKE DECISIONS WHEN YOU KNOW WHAT YOUR VALUES ARE" 〰️ "IT'S NOT HARD TO MAKE DECISIONS WHEN YOU KNOW WHAT YOUR VALUES ARE" 〰️

The h2o 4 l.i.f.e.

© 2023 Restoration Community Development Corporation - All rights reserved.

"IT'S NOT HARD TO MAKE DECISIONS WHEN YOU KNOW WHAT YOUR VALUES ARE" 〰️