Project Rescue

 


Application For Project Rescue Addiction Recovery Program

The Project Rescue Recovery Program is a 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
our Management Team and Charles Baggett.

Please use the Internet Explorer Browser to fill out this
application.

Please call Ronnie Crocker at 256-616-1522
immediately after you submit your 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?
Please explain in detail all of your health issues:
Please list all of the medications you are taking:
Are you willing to sign a liability waiver?

Yes or No?

6-month or 1-year program?:

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

Call 256-303-0784 if you need help submitting the application.