Qualification Form

ROOTS FOR RECOVERY

Scholarship Funding Application and Release of Information
Name *

First Name Last Name
Do you, the above named applicant give consent to the Substance Abuse Relief Foundation (SARF) to contact all names listed and or associated with your application for sober housing funding?
Date *

Month Day Year
Date
D.O.B *

Month Day Year
Date
Sobriety Date *
Can fully pass a urine analysis (drug test)

Yes No
If you can not pass a Urine Analysis please explain why
Phone Number Applicant *
Phone Number of of person filling out applicant *
Email (please list one that you will be able to correspond with IE, moms, dads, clinicians, recovery coach's, PO's, etc etc) *
example@example.com
Home and Address of Interest
Name and number of two personal references
Name and number of one of the following. Parole/Probation Officer, Case worker, Sponsor, Therapist, Recovery Coach, Community Support Specialist, Pastor...etc, etc
Disclaimer -ALL participants MUST pass a urine analysis, fulfill all prequalification’s and be in full agreement to plant and maintain the tree that was donated on their behalf). Substance Abuse Relief Foundation’s (SARF) Roots for Recovery Scholarship is a onetime only payment program designed to assist those who are seeking housing in a recovery type home. The funding is to be dedicated to the first month of rent only. All scholarships are to be used within 7 days of approval. SARF/ Roots for Recovery will not be liable for any payments outside of the initial scholarship. SARF/ Roots for Recovery are not responsible for any outcomes that are attached to said scholarship and will not be liable for any problems that may occur from any participants. *

I have read and agreed with the above disclaimer.
Signature

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ROOTS FOR RECOVERY