Project Rescue Application

Filling out and submitting this application starts the process of entering the Project Rescue Addiction Recovery Program. 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 Jeanie Crocker. Please call Jason Cagle (256) 960-0203 or Rick Talley (256) 441-2365 if you need help submitting the application. The application process only takes 1 to 2 days.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Married

Are you married?

Age

How old are you?

Birthdate

What is your birth date?

Do you currently have your own transportation?

Family Information

Parent or Wife's Contact Information

Parent or Wife's Phone

(###)

###

####

How many children to you have?

List ALL Children's Name / Age / Sex / Mother's Name

Other Information

What type of work skills do you have?

Did you graduate from high school?

Did you attend a university or college?

Do you have a drivers license? Picture ID?

Do you have a social security card?

Do you receive government financial assistance?

Basic Needs Assessment

I need help with financial support for my first 3 months in the program.

My family’s home congregation will provide financial support for my first 3 months in the program.

My family will provide my financial support for my first 3 months in the program.

Please Explain Your Alcohol & Drug Use Below:

List Drug #1 / Age began taking / Amount used last 30 days / Last time used

List Drug #2 / Age began taking / Amount used last 30 days / Last time used

List Drug #3 / Age began taking / Amount used last 30 days / Last time used

List Drug #4 / Age began taking / Amount used last 30 days / Last time used

Please Explain Your Criminal History Below

List Crimes Below with Crime / Date Convicted / Time Served / Date Released

Please list each Crime on a SEPARATE line with information as requested above

Are you a registered sex offender?

Do you have a history of violence?

Additional Information

Please give the name, phone number and minister of the church where your family attends:

Will you attend Bible Studies and church services?

Please list medications you are currently taking:

You can separate each medicine by a comma

Please list any health issues we should be aware of:

Click the Submit button below and this application will be sent to Jeanie Crocker.

Call Jason Cagle at (256) 960-0203 or email jasoncagle42@gmail.com after you submit your application.