Application Date (Today) *

MM

DD

YYYY

Name *

First Name

Last Name

Have you reviewed our program guidelines? *

Yes, I have read over the rules found on the guidelines page.

Due to zoning restrictions Saving Sons is unable to accept registered sex offenders. *

I am not a registered sex offender.

Saving Sons is not a medical facility and does not accept residents currently taking controlled substances, even certain MAT drugs. However, most mental health medications are acceptable at Saving Sons as long as the resident is responsible for administration and refilling their prescription. *

I am not currently on any substances prohibited from use by Saving Sons and can pass a drug test.

I am currently taking a controlled substance such as Suboxone or Methadone and willing to taper off under the supervision of my prescriber.

I am not sober and would be interested in seeking treatment prior to my entry into Saving Sons.

Do you posses a valid government ID? *

Yes

No

Date of Birth *

MM

DD

YYYY

What is your current physical address? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Make sure to leave a phone number that you can be reached by immediately.

(###)

###

####

Are you a biological male? *

Yes

Criminal Background *

Please check all that apply. Checking any of the boxes below does not automatically disqualify you from our program.

I am currently on probation or parole.

I am a convicted Felon.

I have been convicted of a violent crime(s).

I have been convicted of trafficking narcotics.

I have been convicted of a firearms related crime(s).

I have been convicted of a misdemeanor(s).

I have never been convicted of a felony or misdemeanor.

Date of Last Use *

MM

DD

YYYY

Check all that apply.

I have a valid drivers license.

I have a personal vehicle that I would like to bring.

My vehicle has valid liability insurance and registration.

If you are currently in a recovery program/rehab are you leaving on good terms with a referral to Saving Sons?

Yes, I will be graduating/completing my program prior to coming to Saving Sons.

No, I am being dismissed, dropping out, or leaving prior to receiving a certificate of completion.

When would you be ready to enter into the program? *

MM

DD

YYYY

Are you currently able to cover your $100.00 entrance fee? *

Yes

No

Were you referred to our program?

Please name whomever referred you to our program.

First Name

Last Name

Withholding information or being untruthful on your application may result in your disqualification from Saving Sons. *

I have answered all questions truthfully on my application.