Project Rescue Application

Filling out and submitting this application starts the process of entering the Project Rescue Addiction Recovery Program. 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 forwarded to Ronnie Crocker. Please call 256-616-1522 if you need help submitting the application. The application process only takes 1 to 2 days.

Name *
Name
Address *
Address
Phone
Phone
Are you married?
How old are you?
What is your birth date?
Which program are you interested? *
Family Information
Parent or Wife's Phone
Parent or Wife's Phone
Other Information
Basic Needs Assessment
Please Explain Your Alcohol & Drug Use Below:
Please Explain Your Criminal History Below
Please list each Crime on a SEPARATE line with information as requested above
Additional Information
You can separate each medicine by a comma
Click the Submit button below and this application will be sent to Ronnie Crocker.
Call 256-616-1522 or email ronniecrocker1@gmail.com after you submit your application.