Project Rescue

Addiction Recovery Program



Application For Project Rescue Addiction Recovery Program

 

The Project Rescue Recovery Program is a 6-month to 1-year program conducted by Project Rescue, Inc. an Alabama non-profit corporation, primarily for individuals who need help in breaking addictive lifestyles.

We want to help you!

Please fill out this application, click the Submit button (at the bottom of this page) and the completed form will be sent to  ronniecrocker1@gmail.com

Call 256-616-1522 if you need help submitting the application.

Personal Information
Name:
Address:
City / State / Zip:
Home Phone:
Marital Status:
Age:
Birth Date:
Family Information
Parent's or Wife's Contact Information:
Phone:
How many children do you have:
Child's Name Age Sex Mother's Name
If you don't live with your family who do you currently live with?
Live Alone
Live with Spouse
Live with partner other than spouse
Live with friends
Employment Information
What is your Employment status?
Unemployed, Looking for a job
Unemployed, not looking for a job
Part Time Employee
Working for family
Full Time Employee
What type of work skills do you have?
What is your work income $ /month
Other income $ /month
Who is your employer?
Employer Contact Information:
Phone:
Basic Needs Assessment:

Applicant is lacking the resources to provide the $1000 program entry fee and $600 monthly program fee.
Applicant has some resources to provide the program fee.  
Applicant's congregation will provide the program fee.
Transportation Information
Do you currently have your own form of transportation? Yes No
Please Explain Your Alcohol & Drug Use Below:
Drug Age Began Taking Amount Used Last 30 Days Last Time You Used It
Please Explain Your Criminal History Below:
Are you a registered sex offender?
Crime Date Convicted Time Served Date Released
Do you have a history of violence?
Religious Information:
Church Affiliation:
Will you attend Bible Studies and church services?
Are you willing to sign a liability waiver?
Yes or No?

Click the Submit button below and the completed form will be sent to  ronniecrocker1@gmail.com

Call 256-616-1522 if you need help submitting the application.