"Barnabas House - Program Agreement I, Understand that the"
Barnabas House - Program Agreement I, ____________________: Understand that the Barnabas House is a Christian Discipleship Program, and my residency is of a transitional nature and termination without notice is at the discretion of the resident director or program director. I have a contractual agreement not a rental agreement and either party without cause can cancel said contractual agreement at any time. Said cancellation requires the premises be vacated within one hour including removal of all personal property from premises. I agree to pay a weekly program fee of $190.00 by 6:00 P.M. each Friday. I also agree as follows: 1) To follow all rules and Biblical guidelines as directed and if not currently employed, to immediately seek employment. I agree to make it a full time job, from 8 AM to 3 PM daily to diligently apply for at least 8 jobs per day and participate in the Barnabas Employment Assistance Program for help and job search accountability. I acknowledge that I must find a job within 14 days of admission to the Program. 2) To remain alcohol and drug fee during my residency. 3) To submit to any and all drug testing as requested by program or residence director. 4) Not to bring any alcohol, drugs, paraphernalia, or pornographic, or non-Christian material on premises. 5) Not to engage in or be in the presence of any unlawful activity. 6) The Barnabas House is not responsible for your personal property. 7) Attend all church, small group, and Church in the Park meetings. 8) Volunteer for home maintenance and Ministry Programs on a regular basis. 9) Accept changes to rules as determined by director. 10) Commit to a minimum of 6 months stay in the entry program and 6 months in the graduate program. 11) Commit to mutual goals of a growing relationship with Jesus Christ, ministry and community service at any and all available times, a written and adhered to debt management and reduction plan, transportation to and maintenance of regular employment and savings to provide for residence with furnishings. These goals should be reached prior to graduation from program. I hereby declare by my signature below acceptance of the above requirements and understand and agree to abide by them in their entirety, with God’s help. I further understand that Barnabas House policy requires expulsion, without notice of any resident that is found to be using either alcohol or drugs. I acknowledge that disruptive behavior or non-payment of fees can lead to immediate expulsion as well. I understand that I fully subject myself to this policy, including my voluntary and irrevocable waiver of any landlord-tenant rights. I further agree by my signature that my credit, background, references, and any and all information may be released to Barnabas House for the purpose of application review and ongoing review of my residency in this program. Client Signature___________________________________ Date:____________ Witness Signature__________________________________Date:____________ Barnabas House Authorization And Waiver Please take notice that I acknowledge that I am a Client/Resident at the Barnabas House, Sarasota, FL. As such I do hereby acknowledge and agree that it is in my best interest that my paycheck be retained and distributed to Barnabas House representatives. In order to protect my own interest and to ensure that I meet the financial obligations to the Barnabas House. I do hereby willingly and gratefully waive my right to pick up any payments directly from my employer and transfer all such rights to the Barnabas House Financial Director. All pay checks shall be deposited into a general fund, deductions made for program fees and expenses shall be made, and the balance shall be held in my savings account for disbursement to me upon completion of the program. I also give the Barnabas House Power of Attorney to deposit my checks without my signature until all financial responsibilities to the Barnabas House has been disposed. I hold harmless and employment agency or employer and Barnabas House Representative for adhering to this contractual agreement and give my full authorization for said employer to withhold and disburse my paychecks as outlined herein. _______________________________________ ______________ Client Signature Date _______________________________________ ______________ Barnabas House Representative Signature Date Barnabas House Rules And Biblical Guidelines Acceptance Today’s Date:________________ I, _______________________, have read the rules and guidelines. I understand and accept them as a condition of my residency in the Barnabas House. Client Signature:____________________________ Date:______________ Witness Signature:___________________________ Date: _____________ Barnabas House Hold Harmless Agreement As a resident of the Barnabas House, and knowing the purpose of the Ministry of Compassion, I have signed these agreements by my own free will, with full understanding. I hereby release The Barnabas House, all of its agents and representatives from any and all liability whatsoever. This agreement includes, but is not limited to all personnel property, vehicles, whether I am driving or a passenger in same, while I am a resident in the Barnabas House. Signed:____________________________ Date: ___________ Witness:___________________________ Date:____________ Barnabas House Consent For Drug And Alcohol Testing As a resident/client of the Barnabas House, in the interest of safety for all concerned, you will be required to take an urine/saliva analysis for drug and or alcohol use. I, ________________________ Have been fully informed of the reason for this urine/saliva test for drug and/or alcohol (I understand the reason that I am being tested), the procedure involved, and do hereby give my consent. I understand that the results of my test will become part of my record. If the results of the test are positive for drug or alcohol use, I understand that I may be denied entry or dismissed immediately from the Barnabas House. I hereby give my consent for random and or routine drug/alcohol testing for the duration of my residency in the Barnabas House. Client Signature:_________________________________ Date:_____________ Witness Signature:_______________________________ Date:______________ Physician Prescribed Medication Your lawfully prescribed medications must be declared to the program directors and followed during your residency at the Barnabas House as per your doctors’ instructions. Medications may be held and distributed as directed by the House Manager. The residents and staff are not responsible for misuse in any way. Any misuse of prescribed medication by any resident is cause for immediate dismissal. Client Name_______________________ Date:_____________ Physicians Name:____________________ Phone: ___________ Drug Purpose Schedule 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Release: I, _______________________ Hereby fully release and specifically request the above named physician to release any and all medical records for the purpose of monitoring my use of prescription drugs while in the Barnabas House Program. Client Signature:_________________________________ Date:_______________ Witness Signature: _______________________________ Date: _______________ Barnabas House Personal Property List Name _________________________________________________ Date _____________________________ Items brought into Barnabas House: 1) _________________________________________________________________ 2) _________________________________________________________________ 3) _________________________________________________________________ 4) _________________________________________________________________ 5) _________________________________________________________________ 6) _________________________________________________________________ 7) _________________________________________________________________ 8) _________________________________________________________________ 9) _________________________________________________________________ 10) _________________________________________________________________ 11) _________________________________________________________________ 12) _________________________________________________________________ 13) ________________________________________________________________ 14) ________________________________________________________________ 15) ________________________________________________________________ 16) _________________________________________________________________ 17) _________________________________________________________________ 18) _________________________________________________________________ 19) _________________________________________________________________ 20) _________________________________________________________________ Client Signature: _____________________________ Date: ______________ Witness Signature: ____________________________ Date: ______________ Barnabas House Promissory Note/Contract On this _ Day of ___________, 20__, The parties of the Barnabas House and ______________________________, a resident of the Barnabas House, enter into the following agreement. Date Of Arrival In Program: ____________ 1. I, ____________________________, understand and agree that if any personal property remains on the premises after I leave the Barnabas House, through completion of Program or discharge, I shall be charged 10.00/day up to a maximum of 30 days for packing, storing and securing, along with any other expense incurred by the Barnabas House, under Florida Statue, ch 715.107, “storage of abandoned property”. 2. I, _______________________________, understand and agree that after three days of storage, that the “Disposition of abandoned property” shall be executed under Florida statute, ch. 715.100. 3. I, ________________________________, understand and agree that should I leave the program, I will be liable to repay the Barnabas House any and all monies owed. My final balances will be deducted from my savings account. Also, if my account is not paid within 7 days, my unpaid balance will be turned over to a collection agency. Client Signature: _____________________________________ Date: ____________ Witness Signature: ___________________________________ Date: _____________ Barnabas House Resident Application Date Of Application: _______________ Are you a Veteran? ________ Full Name: ______________________________________________PH:_____________ Address: _______________________________________________Cell:_____________ City: _________________ State: ____________ Zip: ____________ Age: _______ Date Of Birth: ____________ Social Security #: __________________ Do you have a valid drivers license? ______ Drivers License #: ____________________ Do you have a vehicle? ______ Make: ________ Model: _________ Tag #: _________ Person to contact in case of emergency: _______________________________________ Phone #: ____________ Address: ____________________________Relation: ________ Second person to contact: __________________________________________________ Are you a member of any church or Christian Organization? : _____________________ Who referred you to this program? __________________________________________ When did you have your last alcoholic drink? ___________________ When was the last time you used illegal drugs? __________________ When was the last time you misused prescription drugs? ___________ Have you been in a Residential Discipleship Program before? ____ When? : __________ Enter Date: ___________ Leave Date: __________ Reason For Leaving:________ ________________________________________________________________ Prior living situation?: ___________________________________________________ (Streets/hospital/jail/prison/friends/relatives/emergency shelter/other) Family History Marital Status: _______________ Name of spouse: _____________________________ Address: ___________________________ City: ______________________ ST: ______ Zip code: ______________ Phone number: _________________ Children_______ Ages/Names: ____________________________________ Child support current? _____ Amount of child support/ Method of payment: _________________________________ Explain custody and visitation with children: ___________________________________ ________________________________________________________________________ Extended Family History Name Age Job Living? Religion? Drug/alcohol problem? Father __________________________________________________________________ Mother _________________________________________________________________ Brothers: ________________________________________________________________ _______________________________________________________________ Sisters: _________________________________________________________________ __________________________________________________________ Fathers Address: ________________________ City: _________ ST: ____ ZIP: ______ Mothers Address: ________________________ City: _________ ST: ____ ZIP: ______ Employment History Are you currently employed? ________ Hours/ Days: ___________________ Employed by: ____________________________ How Long?: __________ Position/job: __________________Responsibilities: _______________________ Employer Address: ___________________________ City: __________ ST: ____ Zip Code : _______________ Phone _____________ Supervisor: ______________ Do you have transportation to work? : __________________ What type of training / skills do you have? : ____________________________________ ________________________________________________________________________ List your last five employers: Previous Employer Position: From – To Reason For Leaving Attitude Toward Job ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Education History How far did you get in school? : Grade: ___ School: _____________________________ City: _____________________ State: ______ Did you graduate? _________________ College/Vocational Training: ____________________________________________ Future Educational Goals: _______________________________________________ Prior/Current Criminal History Current Charges Pending?: _________________________________________________ Explain: ________________________________________________________________ Judge/ Court: ___________________________________________________________ Attorney: ______________________ Phone: ________Appointed or Retained?________ Criminal History: Terms of Probation/ Parole:_______________________________________________ Probation Officer: Name Phone #__________________________________________ All Prior Arrests/Convictions: Date City Charge Disposition (Jail/Prison/Drivers License Action) ________________________________________________________________________ Barnabas House Phases Phase One – 30 Days Orientation must be completed during the first week of residency – and you will be required to participate in the Barnabas Employment assistance program until you have full time employment. 1) You must be accompanied by two other program residents or one graduate / mentor to leave the house. 2) All dinners, church, and meetings are required without prior specific approval. (Phases One – Three) 3) You must sign in and out every time you leave the house and be in the house by 9:00 P.M. every day. 4) You must complete 10 hours of home improvement per month in order to move to Phase Two. 5) Barnabas will administer all finances; you may carry no more than $20.00 Cash. (Phases One – Three) 6) You may not cash paychecks; they must be turned in at Pay-out at 6:00 P.M. Friday. (Phases One –Two) 7) No cursing or violent behavior or speech (All Phases) 8) No ATM, Credit Cards, or checks in your possession without prior approval. (Phases One-Three) 9) No Pornographic or R Rated material, music, videos, MTV, VH1, CMT, Cops, programs promoting drug use, profanity, or sex etc. (All Phases) 10) No relationships for 6 Months unless you are already in one upon entering Program. (Phase One-Three) 11) If you are married or in a relationship there is no visitation without supervision. (All Phases) 12) Visitation is limited to one weekday dinner and one three to four hour weekend visit per week 13) Visiting children must be supervised by parent at all times. (All Phases) 14) Phone calls are limited to ten minutes (Cell or house phone) (All Phases) 15) No phone calls after 10:00 P.M. (Cell or house phone) (All Phases) 16) No evening, Sunday, or midnight work is allowed – (All Phases – no exceptions) 17) You must submit to drug testing on demand. (All Phases) 18) All rules must be adhered to and all household chores must be completed by 10 pm ($10. fine plus 2 additional task hour penalty for non-compliance) Phase Two – 60 Days 1) You must be accompanied by one other program resident or approved family member to leave the house. 2) You must complete 7 hours of home improvement per month to move to Phase Three. 3) You must sign in and out every time you leave the house and be in the house by 9:00 P.M. weekdays and 10:00 P.M. Friday/Saturday. Phase Three – 90 Days 1) You must sign in and out every time you leave the house. 2) You must complete 5 hours of home improvement per month to move to Phase Four. 3) You must be in the house by 10:00 P.M. Weekdays and 11:00 P.M. Friday/Saturday. Phase Four – 6 Months – Graduate 1) You must be accountable for your whereabouts to other graduates/ house leaders at all times. You must sign in and out every time you leave the house. 2) You must complete 3 Hours of home improvement per month to remain in phase Four. 3) You must be in the house by 10:00 P.M. Weekdays and 11:00 P.M. Sat/Sun without prior approval. 4) You must honor God in all relationships. 5) You may choose to manage your own finances if all fees are current & paid. If fees become in arrears at any time, Barnabas management will require that all income be submitted as in phase 1 sec. 6. 6) You are expected to serve at all meetings and church with occasional exceptions. ___________________________ _________ _________________________ _________ Signature Date Witness Date