TRUST GOD * CLEAN HOUSE * HELP OTHERS
THE SURRENDER HOUSE
APPLICATION (PRINT AND BRING AT INTAKE)
Recovery Residence *CAPE CORAL*FORT MYERS
KARI-ANNE SPILLER -PROGRAM DIRECTOR *239-333-8079
General Information: (PLEASE PRINT) Name:
(Last) ___________________________ (First) ___________________________ (MI) _________________
Street: __________________________ City: ____________________ State: ______ Zip: _____
S. S. #: __________ - ________ - ___________ Drivers License/State ID: _________________________
Birth Date:_____/_____/_____ Cell #: ________ - ________ - _________
In Case of Emergency: Name: ___________________________ Relation: _______________
Name: __________________________ Relation: _______________ Tel: _______________
Are you on: Probation: ____ Y, ____N
Drug Court Involved: ____ Y, ____N
PO Name: _______________________________________ Phone #: _______ - _______ - _________
Lived at Surrender House before? _________ When/Where?_________________________________
Fort Myers Men ($175 per wk ) _____
Cape Coral Men ($175 per wk) _____
Cape Coral Women ($175 per wk)_____
**NON REFUNDABLE administrative fee is equal to 1 weeks rent at each location**
Reason for Medication(s): _________________________________________________________________________
Have you ever been ARRESTED for a sex crime YES______ NO ______
PRINT NAME: ______________________________________________
SIGNATURE: _____________________________________________ DATE: ___________________
Educating Our Community * Saving Our Families * Proving God and The 12 Steps work