If you are a human and are seeing this field, please leave it blank. 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 forwarded to Ronnie Crocker. Please call 256-616-1522 if you need help submitting the application. Please use the Internet Explorer Browser to fill out this 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 $2000 program entry 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? Will you commit to Project Rescue’s 1-year program? Click the Submit button below and this application will be sent to Ronnie Crocker. Ronnie will forward it to Charles Baggett and the Management Team. Call 256-616-1522 if you need help submitting the application.