Application for U-Turn for Christ Kaua'i Recovery Program

Please FAX or email this initial application back before admittance will be accepted. Fax: 888-765-3809

Name of Prospective Attendee:____________________________________________

Birthdate:  ___/___/_____           Single____ Married____ If Married, how long?____ Divorced_____

Children  & Ages_____________________________________________________


Phone Number: Cell_________________ Home:________________

Possible date to enter program: ______________________________

Contact Person Name Other than You: (Mother, Father, Wife, Relative): _______________________________________

Contact Person Address: _________________________________________________________________________

Contact Phone Number: Cell_________________ Home:______________________


In Case of Emergency Contact___________________________________________________________________

Highest Education Completed:___________________________________________________________________

How did you hear about us?

List all substances/addictions that you are struggling with:

Please tell us why you would like to come to our program:

Have you accepted Jesus Christ as your Lord and Savior?_____ Y _____N  

If yes, when and give us a brief testimony and age:

If no, you understand that we are a Bible based, Christian recovery program that will be requiring study of the Bible, attendance at various church services and Bible studies, and that memorization of scriptures as part of your recovery ______ Initials

Are you currently under the care of any physician or health care practitioner for any reason? ____Y_____N

If Yes, please state reason(s): ______________________________________________________________


Are there any other psychological or emotional challenges that we should know about? _____________________


Are you currently taking any prescription or over-the-counter medications for any reason?  _____Y _____N 

If yes, please list them here and for what purpose they are taken: 


Insurance information:  Name of Company:_____________________________ Policy #_________________________

Do you have Dental Insurance? _____Y _____N  

Name of company: ______________________________Policy #________________________________

All necessary medications (such as for blood pressure, diabetes) must have your name imprinted from the pharmacy and include a doctor’s note as to the prescription and need. No narcotics will be allowed including Suboxone! ______Initials

Any other medications such as anti-depressants, mood stabilizers etc... will be weaned off 25% per week____Initials.

There are no other medications/drugs/substances that I am taking that I have not listed on this application ______Initials

Are there any outstanding tickets, warrants or any other legal issues you have to deal with? ____Y _____N

If yes, please explain:

Do you have any upcoming court dates or a need to appear in person for legal issues?  _____Y ______N

Parole Officer Name:________________________________Phone #:_______________________________

U-turn for Christ Kauai (UTFCK) is a non-smoking ranch.  It is understood that this may be an additional addiction that you have and will be recovering from at UTFCK. Please initial that you acknowledge that you will not be smoking while in our program and will not bring any tobacco products onto the ranch at any time. _____ Initials

The U-Turn for Christ program involves possible construction jobs, community service and physical activity.  Do you have any physical impairments that would keep you from working in any activities? If so, please list here:

I have no physical impairments  at the time of my entry into the program of U-Turn for Christ Kaua'i ______Initials

Do you have any special skills that you would be able to contribute with to the ministry while you are in our program? (such as 
construction, carpentry, mechanical, computer, ect.)

I understand that I may not bring a cell phone or computer to the program during 1st Phase, and that any such electronics will be donated to the ministry of UTFCK.  _____Initials

All personal items brought to the program including but not limited to Ipod, clothing and any other items are brought with the understanding it is at your own risk and no U-Turn for Christ Kaua'i can take no responsibility for these items.  _____Initials

It is suggested that you use an indelible marker to write your name or initials on your articles of clothing.

Prospective Attendee Signature______________________________________  

Print Name____________________________________Date______________

Witness_________________________Print Name_________________________Date______________

Financial Responsibility:

Who is financially responsible for the donation to the program and any other needs (Medical or Personal) while attending the program of UTFCKauai? Name: ________________________________ Relationship:______________________

I will take full financial responsibility for above attendee and if any medical or dental issues that are not covered by insurance that require payment come up while attendee is in UTFCKauai, I will pay for any and all needs.  Also, if attendee leaves the program or is asked to leave the program, and attendee does not return in acceptable time, financially responsible person will obtain an airline ticket to bring attendee home if they are not local to the island of Kauai. 

_____________________________Signature                    _________________Date

Please note that donation is non-refundable.  Donation online or by check/MO constitutes acceptance of non-refundable policy. If the resident walks from the program, he assumes all costs and liability from his actions and does not hold U-turn for Christ Kauai or any of it's affiliates liable. There is a $100 restart fee each week that the attendee is charged if the attendee walks and returns up to 4 weeks for a total of $400.  After 4 weeks, the entire donation of $3,450.00 is requested to restart the program.  Donation is requested to be paid within 3 days of him returning by financially responsible party that signs application below.

We reserve the right to refuse acceptance to our program.  Acceptance is based on desire to recover and to follow the directions of the overseers and Director. If a resident is non-compliant and decides not to follow the input or guidance of the program, he will be asked to leave and no refund will be given regardless of the time he has spent in the program. . We are a faith-based program, soley on the Word of God: the Bible.

Financially Responsible Party:

I,  (Print Name:) ___________________________________, (Relationship to Prospective Attendee)_________________

take financial responsibilty for ___________________________ and will see that his needs are taken care of while in the 

program of U-Turn for Christ Kauai.  If he leaves or is asked to leave the program, I will obtain an airline ticket for him to return  

home if he does not return to the program and pay the donation in the allowed time. 

Signature: _________________________________ Date:___________________________

Address:_____________________________________ Phone:_____________________________

U-Turn for Christ Kaua'i
951-204-2165 Intake Coordinator's Cell

Office Use:  Date Received_____________Accepted:  Y_____N_____ Date of Entry__________________

 Method of payment of donation:  Check: ________ CC_______Received Date: ______________________

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