______ I understand that I am enrolling in a recovery program and I agree to abide by all of its policies and guidelines if I wish to remain in Foundations in Recovery.
______ I understand that I must work a personal program of recovery while in the Foundations in Recovery program. I agree to follow the guidelines and attend the minimum required one 12-step meeting per day for 90 days (with attendance sheet) and five 12-step meetings a week thereafter; and obtain a 12-step sponsor, home-group, literature, phone numbers, etc.
______ I agree to abstain from all drugs, including alcohol, while in the Foundations to Recovery program and will submit to a drug test whenever I am asked by the acting resident manager or the program director.
______ I understand that lying on my intake application could result in my dismissal from the program, my removal from the premises and my surrender of prepaid program fees.
______ I understand that it is my responsibility to timely pay program fees at 10 p.m. each Friday if I wish to remain in the Foundations in Recovery program. I understand I must get and stay at least two weeks ahead in my fee payments. Within the first two months I agree to make extra payments each week or a lump sum payment to achieve this.
______ I understand and agree that in the case of a returned check, I will pay the full amount due in cash, plus a $35.00 return check charge. Thereafter, checks will no longer be an accepted form of payment.
______ I understand that any violation of the zero tolerance policy may result in my immediate discharge from the Foundations in Recovery program. Should I be discharged from the program, I agree to gather my personal items and peacefully vacate the premises within thirty minutes of being asked to leave.
______ I understand that if I bring any illegal substance or weapon(s) onto Foundations in Recovery property and/or if any of my actions cause physical harm to client’s, staff’s, or a neighbor’s person or property, the police will be called which could lead to my arrest.
______ I understand that if I am discharged from the program for violating any Foundations in Recovery policies and guidelines, that there will be no refund of prepaid fees; and that no fees will be pro-rated for moving out early in the week. Upon discharge or voluntary vacancy, it will be the member’s responsibility to remove personal belongings from the premises. If personal effects have not been removed within 24 hours, they will be stored for thirty days. Thereafter, they will be donated or discarded at the option of the director.
______ I understand and accept that I am not a tenant; that any stay in any Foundations in Recovery transitional living home is due solely to my enrollment status in the recovery program; that I do not have any tenant rights to eviction, and I can be discharged from the program without any due process of law. If I am asked to leave the premises, I will exit within 30 minutes.
AUTHORIZATION TO USE OR DISCLOSE PROTECTED IN INFORMATION
______ I authorize the use or disclosure of protected information as related to my status as a resident at one of the Foundations in Recovery program homes. This information is to pertain to the level of my participation in and compliance with the program guidelines, which includes the results of drug and alcohol screening and any medical emergencies. 
______ I have read, understand and agree to adhere to the Foundations in Recovery policies and guidelines. The resident manager and/or program director went over each section of the policies and guidelines very carefully with me and I have received my own copy of them. I am aware that my stay in a Foundations in Recovery home is completely contingent upon my enrollment status and participation in this recovery program. I understand that the policies and guidelines are in place to protect everyone in the program and to help Foundations in Recovery fulfill its program mission which is to: provide a safe, supportive and substance free environment for recovering men to develop the necessary tools to pursue a life free from alcohol and drug addiction. I give the Foundations in Recovery program the absolute power to expel me from the program if deemed, by the director or the acting resident manager, to be in the best interest of the program and/or its members and I agree to leave the premises peacefully. Should I refuse to leave upon dismissal, the local police department will be called to help escort me off the property. I agree to hold Foundations in Recovery harmless in the event of injury during my removal.
Member Signature __________________________________ Date _______________
Print Full Name ________________________ Telephone Number (____) __________
Director’s Signature _______________________
Resident Manager _______________
I have been informed of the specific type(s) of information that may be requested and of the benefits and/or disadvantages of releasing the above information. I understand that this consent is subject to revocation by me at any time except to the extent that action has been taken in reliance on this consent prior to revocation. Revocation of authorization must be presented to Foundations in Recovery in writing. I absolve Foundations in Recovery from any and all damages, claims, causes of action arising out of or in connection with, the release of this information.