Application Form

Application for R.O.P.E. House Residential Program

Please fill in the form below.
PROGRAM REQUIREMENTS

Program requirements have been established for the purpose of ensuring that residents remain focused and undistracted from their goals and plans of active recovery. Behavior contrary to the program rules will be subject to review and ultimately dismissal from the program.

The Program Requirements are:
1. Mondays through Fridays from 7 AM to 6 PM are designated program hours. Residents are expected to be on the premises and participating in program activities unless they are engaged in offsite programming; working, medical care or have obtained authorization from a R.O.P.E. House Caseworker or Program Director.
2. Saturday & Sunday activities outside the house must be preapproved by Program Director. Passes are granted at the discretion of the Program Director. Residents must be in good standing and have demonstrated that he is capable of handling his pass request.
3. Residents are expected to meet with Caseworkers at least once weekly to discuss their progress in achieving their goals and address any obstacles to their success.
4. Residents are expected to deposit 75% of their income from any source into a Resident Savings Account (Joint Savings Account established with R.O.P.E.), which will be held for them until the completion of their residency.
5. Residents are not to open checking accounts unless they have the approval of their caseworker.
6. Residents are asked to refrain from personal romantic relationships while in the program, which is found to compromise their recovery. If it is found out that a resident is involved in a relationship, he will be asked to leave the program.
7. Residents who are not attending programs or working may be asked from time to time, to assist in tasks related to the operations and administration of the agency. They are expected to do so to the extent of their abilities.
8. Residents who have been prescribed psychotropic drugs are expected to follow their courses of medication.
APPEAL PROCESS

Residents who believe that they have been unjustly cited for a breach of R.O.P.E. rules, or who believe that any penalty/ies that have been imposed are unduly severe, can appeal with their assigned caseworker. If the resident remains unsatisfied with the response, he should speak with the R.O.P.E. Program Director or in his absence the Director of Operations. If the resident is not satisfied, he may make a final appeal to the Executive Director of R.O.P.E. House.
R.O.P.E. Program Cardinal Rules & Resident’s Agreement

Cardinal Rules:
1. No weapons
2. No alcohol or narcotics
3. No stealing
4. No damage to R.O.P.E. House Property
5. No gambling on campus
6. No sex on campus
7. No violence or threats of violence on campus
8. No fighting on campus
9. No television or radio playing during program hours which are 7 AM to 4:30 PM
10. No loitering around or trespassing on property adjacent to R.O.P.E. House
11. No borrowing or loaning of money
12. No Cell Phones. If a resident is found to have a cell phone, he will be asked to leave the program.
I Agree:
1. To cooperate with the R.O.P.E. House Staff and other residents.
2. To show respect to myself and others.
3. To do my work assignments.
4. To keep myself and my quarters clean.
5. To adhere to the rules of the R.O.P.E. House.
6. To provide a forwarding address and to file a change of address upon any discharge. I understand that R.O.P.E. House will hold my mail for 10 business days after my discharge and upon my request and after the 10 days my mail will be returned to sender.
MEAL TIMES

Residents are responsible for preparing meals during meal times as long as it does not interfere with program responsibility. Residents typically take turns preparing meals and cleaning the kitchen. No food or beverages of any kind are to be stored or consumed in bedrooms.

DRESS CODE

Residents are to be appropriately dress at all times and in all areas of the House. Unacceptable: No shoes or sleeveless shirts in the dining room. No hats, headbands, scarves in the house. Pajamas and robes are to be worn in common areas.

LAUNDRY ROOM

The laundry room may not be used during House Meetings or between the hours of 10:00 PM – 8:00 AM each day.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Today's Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Date
Ethnicity*
Institution*
Scheduled Parole Date*

MonthDayYear
Date
Social Security Number*
Martial Status*
# of Children*
Committing Offense:*
Sentence*
Actual Time:*
Date Sentenced:*

MonthDayYear
Date
Have you ever been incarcerated before?:*
If yes, when?
Please attach incarceration history or any other pertinent history/information

Browse Files

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Have you ever been in the R.O.P.E. house before?*
If yes, when?
Medical History
Please list all medical issues/problems:*
Type N/A if this does not apply
lease list all medications for physical/psychiatric issues:*
Type N/A if this does not apply
SUBSTANCE ABUSE
Have you ever used drugs (including alcohol)?*
If yes, please identify those used:
How old were you when you first used?
What did you use?*
Type N/A if this does not apply
Were you under the influence of drugs/alcohol when arrested?*
Do you know what your triggers are?*
If so, what are they?
Have you ever been in a detox program?*
If yes, for what, when, and where were you admitted:
E-mail*
Sex OffensesArsonSelling DrugsViolent OffensesN/A
FAMILY
Please list significant family members and addresses*
Do you eventually plan to live with family members?*
If yes, which one?
Are you or have you been involved with selling drugs?*
Do you have problems concerning lifestyle issues?*
Are you from the Waukegan community?*
If the answer is yes, how long?
EDUCATION & EXPERIENCE
Which do you have?*
Please list any skills training or trades you possess?*
Do you have any college credits?*
If yes, please explain
Have you ever held a job for longer than one year?_*
If yes, what did you do?
Is there a reason why you may be unable to work?*
If yes, please explain:
Please explain why you are applying to the R.O.P.E. House and why you should be admitted to this program*
DEPARTMENT OF CORRECTIONS

CONSENT OF DISCLOSURE OF CONFIDENTIAL INFORMATION TO R.O.P.E. HOUSE PROGRAM.

I hereby authorize disclosure by the Illinois Department of Corrections, the Parole and Pardon Boards and their agents of my file information and records to the extent necessary for the R.O.P.E. House to make an adequate plan for my residency in their program. I understand that such information will be treated according to the Unified Code of Corrections, Chapter 38, 100351(b) and administrative regulations 844 and 846. I also understand that I may withdraw this consent at any time, and that in granting this withdrawal the aforementioned agencies will cease and desist from sharing my information.
By signing this application, I understand and agree to abide by the Cardinal Rules and to fulfill the agreements stated above and that all information entered by the applicant is correct.
Applicant Full Name*

First NameLast Name
Applicant Signature*
Applicant Photo Required*
Date*

MonthDayYear
Date
Witness Full Name*

First NameLast Name
Witness Signature*
Date*

MonthDayYear
Date
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Application for R.O.P.E. House Residential Program