E-FORM

First NameLast NameDate of BirthStreet AddressApartment/Unit #CityStateZipcodeCell PhoneWork PhoneEmailSponsor NameSponsor Work PhoneIf currently residing in a Treatment Facility, please list below:Do you attend AA/NA Meetings?Do you want to stop drinking/using drugs?Are you an alcoholic?If yes, please date the last your last drinkPlease list below drugs used addictivelyWhat is your gross monthly income?Are you Married?Are you employed?If yes, who is your employer?What do you expect your monthly income to be next month?How many AA meetings do you attend each week?Do you take prescription drugs?If yes, please list drugs and reason.Do you have a medical doctor?If yes, please list their name and phone number.Have you ever been to a Treatment Facility for drug and/or alcoholism?If yes, please list the facility, and your provider's name and phone number below:Are you ready to move in?If NO, please provide a move in date.If NO, please provide a reason for a future move in date.Have you ever lived in a Legacy Sober Living Home before?If yes, please provide the name and location.If yes, please provide the reason for leaving previous home.I am aware that if I owe money to the previous Legacy Sober Living Home, I agree to repay the money I owe.Please list below any emergency contacts below including their name and phone number

To be accepted in a Legacy Sober Living House, an applicant must complete both pages of this application; be interviewed by the residents of the particular Legacy Sober Living House to which the applicant is applying. The residents of the house then vote on acceptance. An 80% affirmative vote is needed to be accepted. Carefully read the application and honestly answer the questions above. Living in a Legacy Sober Living House is unique and if you understand its value it can assist in achieving a calm and complete sobriety without relapse

I realize that the Legacy Sober Living House to which I am applying for residency requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share household expenses including the monthly lease payment, among all residents, and (D) utilize democratic decision making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant excludes himself or herself from the normal due process afforded by local landlord-tenant laws.

I have read all material on this application form. I have also answered each question honestly and want to complete calm consistent recovery from alcoholism and/or drug addiction without relapse.

E-SIGNATURE

Thank you! Your application has been received!

Please allow Legacy House staff 2-3 busniess days to review your application and contact you regardding admission status.

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Membership Application

E-FORM

I have read all material on this application form. I have also answered each question honestly and want to complete calm consistent recovery from alcoholism and/or drug addiction without relapse.