Please email this initial application and call Intake Coordinator, Ceci, for a phone interview.
Email: UturnforChristKauai@gmail.com . Payment can be made on the support page donation button after acceptance to the program is given.
Name of Prospective Attendee:____________________________________________
Birthdate: ___/___/_____ Single____ Married____ If Married, how long?____ Divorced_____
Children & Ages_____________________________________________________________________________
Current Mailing Address: ______________________________________________________________________
Phone Number: Cell: _________________ Home: ________________
Possible date to enter program: _______________________________,
Contact Person Name Other than you:(Mother Father, Wife, Relative (Circle): ______________________________
Contact Person's Address: _________________________________________________________________________
Contact Phone Number: Cell_________________ Home:______________________
Email:_______________________@__________________________
In Case of Emergency Contact: _________________________________________________________________
Highest Education Completed:___________________________________________________________________
How did you hear about us?
List all substances/addictions that you are struggling with:
Please tell us why you would like to come to our program:
Have you accepted Jesus Christ as your Lord and Savior? _____ Y _____N
If yes, when and give us a brief testimony and age:
If no, you understand that we are a Bible based, Christian recovery program that will be requiring study of the Bible, attendance at various church services and Bible studies, and that memorization of scriptures as part of your recovery ______ Initials
Are you currently under the care of any physician or health care practitioner for any reason? ____Y_____N
If Yes, please state reason(s): ______________________________________________________________
_____________________________________________________________________________________
Are there any other psychological or emotional challenges that we should know about? _____________________
_______________________________________________________________________________________
I do not have any known psychological or emotional challenges I have not stated ______Initials
Are you currently taking any prescription or over-the-counter medications for any reason? _____Y _____N
If yes, please list them here and for what purpose they are taken:
PLEASE BRING YOUR INSURANCE CARD WITH YOU IF ACCEPTED
Insurance information: Name of Company:_____________________________ Policy #_________________________
Do you have Dental Insurance? _____Y _____N
Name of company: ______________________________Policy #________________________________
All necessary medications (such as for blood pressure, diabetes) must have your name imprinted from the pharmacy and include a doctor’s note as to the prescription and need. NO other medications including but not limited to anti-depressants, mood stabilizers and narcotics will be allowed including Suboxone! ______Initials
Any medications such as anti-depressants, mood stabilizers etc... must be completed before coming to the ranch. No medications other than for high blood pressure or diabetes can be administered and are not allowed on the premises. Please call to discuss if you have any other medications you are currently taking.
There are NO other medications/drugs/substances that I am taking that I have not listed on this application ______Initials
Are there any outstanding tickets, warrants or any other legal issues you have to deal with? ____Y _____N
If yes, please explain:
Date: Location:
Have you ever been incarcerated: ___Y ___N Date(s) _____________________
For what reason:
Are you required to check in with a parole officer: ____Y ____N If Yes, how often? ____________________
Do you have any upcoming court dates or a need to appear in person for legal issues? _____Y ______N
Parole Officer Name:________________________________Phone #:_______________________________
U-turn for Christ Kauai (UTFCK) is a non-smoking ranch. It is understood that this may be an additional addiction that you have and will be recovering from at UTFCK. Please initial that you acknowledge that you will not be smoking while in our program and will not bring ANY tobacco products onto the ranch at any time. _____ Initials
The U-Turn for Christ program involves painting, possible construction jobs, community service and physical activity. Do you have any physical impairments that would keep you from working in any activities? If so, please list here:
I have no physical impairments at the time of my entry into the program of U-Turn for Christ Kaua'i ______Initials
Do you have any special skills that you would be able to contribute with to the ministry while you are in our program? (such as construction, carpentry, mechanical, computer, ect.)
I understand that I may not bring an Ipod, cell phone or computer to the program, and that any such electronics will be donated to the ministry of UTFCK. _____Initials
All personal items brought to the program including but not limited to clothing and any other items are brought with the understanding it is at your own risk and U-Turn for Christ Kaua'i takes no responsibility for these items. _____Initials
It is suggested that you use an indelible marker to write your name or initials on your articles of clothing.
Prospective Attendee Signature______________________________________
Print Name____________________________________Date______________
Witness_________________________Print Name_________________________Date______________
Financial Responsibility:
Who is financially responsible for the donation to the program and any other needs (Medical or Personal) while attending the program of UTFCKauai? Name: ________________________________ Relationship:______________________
I will take full financial responsibility for above attendee and if any medical or dental issues that are not covered by insurance that require payment come up while attendee is in UTFCKauai, I will pay for any and all needs. Also, if attendee leaves the program or is asked to leave the program, and attendee does not return in acceptable time, financially responsible person will obtain an airline ticket to bring attendee home if they are not local to the island of Kauai.
_____________________________Signature _________________Date
Please note that $3450.00 donation is non-refundable. Donation by credit card, check/MO constitutes acceptance of non-refundable policy. If the resident walks from the program, he assumes all costs and liability from his actions and does not hold U-turn for Christ Kauai or any of it's affiliates liable.
There is a $100 restart fee each week that the attendee is charged if the attendee walks and returns, up to 4 weeks for a total of $400. After 4 weeks, the entire donation of $3,450.00 is requested to restart the program. Donation is requested to be paid within 1 day of him returning by financially responsible party that signs application below.
We reserve the right to refuse acceptance to our program. Acceptance is based on desire to recover and to follow the directions of the overseers and Director. If a resident is non-compliant and decides not to follow the input or guidance of the program, he will be asked to leave and no refund will be given regardless of the time he has spent in the program. . We are a faith-based program, solely on the Word of God: the Bible.
Please Call Ceci at 951-204-2165 to make payment.
Financially Responsible Party:
I, (Print Name:) ___________________________________, (Relationship to Prospective Attendee)_________________
take financial responsibility for ___________________________ and will see that his needs are taken care of while in the
program of U-Turn for Christ Kauai. If he leaves or is asked to leave the program, and does not return in the acceptable time, I will obtain an airline ticket for him to return home if he is not local to the island of Kauai. I understand that the donation is non-refundable for any reason.
Signature: _________________________________ Date:___________________________
Address:_____________________________________ Phone:_____________________________
U-Turn for Christ Kaua'i
951-204-2165 Intake Coordinator's Cell
UturnforChristKauai@gmail.com
Office Use: Date Received_____________Accepted: Y_____N_____ Date of Entry__________________
Method of payment of donation: Check: ________ CC_______Received Date: ______________________
