Application

INSTRUCTIONS

Please fill out each field. If there is a question that doesn't apply write NOT APPLICABLE. In order to submit your application every question must be answered.

APPLICATION FORM

1. Personal Information

* Indicates required field

Name *

First

Last

Address *

City *

State *

Zip *

Phone Number *

Date of Birth *

Social Security *

Driver's Licence # *

1. What is your current status? *

In A Relationship Married Single Divorced

2. Do you have any children? *

Yes No

If you have any children, please list their names and ages in the space below

Child/children's name and ages *

Place of Employment *

How long have you worked there? *

Write a short paragraph about your abuse of drugs, alcohol, or life controlling problems. *

2. Legal Information

1. Are you currently on probation or parole? *

Yes No

2. If yes, please provide the name and informationof probation or parole officer below

Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

3. How often do you report? *

4.Do you physically report, or e-mail in report? *

5. Do you owe fines? *

Amount *

Due Date *

6. Are you registered sex offender? *

Yes No

7. Have you ever been convicted of a violent crime offense? *

Yes No

If yes, explain *

8.Do you have court cases pending? *

Yes No

If yes, please explain when and where. *

3. Religion

1. Do you attend church? *

Yes No

If so, what church do you attend? *

Pastor's Name *

Pastor's Phone Number *

2. Have you made a commitment to serve Jesus Christ? *

Yes No

3. If so, where? *

4. Purpose

1. My purpose for applying the Arise Residential Program is: *

2. What are your goals? *

5. REFERENCES

Please provide a reference and contact information below.

Name *

First

Last

Phone Number *

Street Address *

City *

State *

Zip *

6. MEDICAL INFORMATION

1. Are you currently under a doctor's care? *

Yes No

2. If yes, please explain below. *

3. Dr.'s Name *

First

Last

Dr.'s Phone Number *

Medications: Life sustaining medications only. For example: heart and blood pressure medications. Psychotropic medications are NOT life sustaining medications. Arise does not allow any psychotropic medications in the program. Any person requesting entry into the program and currently taking psychotropic medication must have a Step-down schedule prescribed by their doctor to be submitted with this application. If you already have one, please scan and upload below.

Doctor's Prescription *

Max file size: 20MB

4. Please list all life sustaining medications: *

5. Do you have any allergies? *

Yes No

If yes, please list *

6. Do you have any physical limitations that would inhibit your ability to perform manual labor? or example: A history of herniated or slipped disc in the back, hip or knee injuries, neck or shoulder injuries. If so, please list. *

Note: A doctor's note, on their office stationary, stating the specific physical limitation (s) is REQUIRED before admission to the program and should be submitted with this application. ARISE is staffed to transport residents to and from medical and dental appointments. Therefore, any medical and dental problems must be addressed prior to entry into the program. Medical and dental emergencies will be attended to in the appropriate manner.

7. MINISTRY RELATIONSHIP

I understand that ARISE is a religious, Biblical based organization, a ministry of Machias Christian Fellowship. The purpose of Arise is to process new creatures in Christ into people of honor, prepared to take their place, first of all, in the fellowship of believers (regular church attendance) and secondly, return to live and work, brush shoulders with the rest of the world while remaining clean. "Clean" means no alcohol and no use of drugs.

Choose One *

Agree Disagree

Please type your name below as a legal signature to this application and to agreement to the statement above.

Signature *

First

Last

Date *

8. DRUG TREATMENT

I understand that Arise is not licensed by the state of Maine as a drug treatment program.
Please type your name below as a legal signature to this application and to agreement to the statement above.

Signature *

First

Last

Date *

Note: After completely filling out this application and submitting it either by e-mail, through the website or by mail to: 11 Lincoln Street, Machias, ME 04654, you should contact the program director, Paul Trovarello, to make an appointment for an interview at 207-271-7060. If you choose to mail your application, please allow 4 to 5 business days before contacting us. You must call and be approved before coming into the program. During the interview prior to entry you will be asked if you have taken drugs or alcohol in the past 24 hours. Please note that circumstances may require you to go through a detox center before coming into the program.

9. Financial Agreement

A $5,000 tuition fee will be turned in prior to your program entry.
A money order or cashier's check is required. No personal checks will be accepted. This fee is non-refundable.
If the resident leaves the program for any reason, there will be no refund of any part of this fee.
In situations of hardship a financial contract may be negotiated with program administrator.

I have read the above disclosure statement. I understand and agree to abide by these terms. Please type your name below as a legal signature to this application and to agreement to the statement above.

Name and Last Name *

First

Last

Date *

10. FOR OFFICE ONLY

If you are the applicant, please do not fill this section out.

REVIEWED BY DIRECTOR: ___________________________________________________ Date:________________________________________

DATE FAXED: ________/________/_________ DATE RECEIVED:_________/_________/________ DATE:_________/_________/__________

DATE ENTERED IN PROGRAM: ________/_________/_________ APPROVED BY: _______________________________________________

REVISED: 12/1/15

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