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:
PLEASE BRING YOUR INSURANCE CARD WITH YOU IF ACCEPTED
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______________________________________
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.
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:___________________________
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: ______________________