Welcome Home Web Site Application for Program Entry First Name * Last Name * Cell Phone * Sobriety Date * Date of Birth * Age * Email Address * Race/Ethnicity Asian Black/African Caucasian Hispanic/Latino Native American Pacific Islander Other We use this demographic information to apply for additional funding. Emergency Contacts, including sponsor Contact 1 Name * Contact 1 Relationship * Contact 1 Phone Number * Contact 2 Name * Contact 2 Relationship * Contact 2 Phone Number * Contact 3 Name Contact 3 Relationship Contact 3 Phone Number Agreements When moving into The Way Homes ministry home, you agree to the following: 1. To stay clean and sober from all drugs and alcohol. Only drugs that are taken as prescribed will be allowed. A complete list will be presented to the proper authority immediately. 2. To submit to drug testing immediately at your own expense upon request of TWH staff. 3. To adhere to any and all house rules stated either verbally or in the welcome packet. 4. To live in harmony with others and show utmost respect to those in authority of the home. 5. To pay agreed upon rent at time due. Anyone, who by circumstances beyond their control, becomes late or delinquent in their rent, will be required to produce pay stubs from their employer to show proof of income until all back rent is brought current. No exceptions. 6. To cooperate in the running of the homes as a peaceful environment. Exit Expectations: 1. You understand that The Way Homes is not a “way over.” It’s not designed for you to catch your breath, get physically well, feel better and move back to your best way of thinking. Rather, its purpose is to help you find a new way of thinking. 2. You understand that it’s a home where, with other roommates, you grow in not only physical strength while abstaining from drugs, alcohol and other sin that distracts us from growing; but is a place to grow spiritually mature, always understanding that none of us are perfect. Its “progress not perfection.” 3. You understand that when you moved here, you agreed to be working a Christ-centered 12-step program with a sponsor. 4. You understand that when leaving, you are expected to give at least two weeks’ notice and also agree to sit down with your sponsor and us to share your exit plan. If you do not have a sponsor, you need to bring a "brother" or "sister" in the program to fill in as a sponsor. 5. You understand that the security deposit is returned only upon fulfilling all agreed-upon conditions. No exceptions. By typing my name below, I agree to all the above and understand that any violation will be cause for immediate removal from the home. In addition, I agree to waive any eviction process that would normally be granted under Anne Arundel County or Maryland state laws. Full Name * Today's Date * Witness Full Name * Witness Phone number * Please complete all questions below: Family/Relationship Status * Single In a Relationship Married Legally Separated Divorced Widowed Do you have children who are minors? * Yes No Briefly describe your current living situation and circumstances before coming into The Way Homes * Are you enrolled in Medicaid or any other health Insurance? * Yes No Medical information: list existing conditions, allergies, etc. *Be sure to list all current prescriptions, including all opioid drugs, that you are taking * Do you have a history of opioid abuse, ever completed a detox program? If yes where and when? * If you have participated in any other rehabilitation programs, please list when and where. * List any pending court dates, probation, outstanding warrants or other unresolved legal matters: * Do you have a driver’s license or State ID? * Yes No State the Driver's License or ID was issued in (ie. MD) * Driver's License or State ID number * Are you able to legally drive? * Yes No Do you have a vehicle? * Yes No Current or most recent employer: * Supervisor Name Supervisor Phone number Employment Status * Employed Full Time Employed Part Time Self-Employed Unemployed Please describe your work history, qualifications, skills, experience, etc * Current or previous home church name Pastor Name Pastor Phone number How did you come to know about The Way Homes? * By submitting this form, I hereby certify that every statement I have made in this application is true and complete to the best of my knowledge.