LEGAL RELEASE

Confidential Release

I hereby grant a full release of any information in my life, whether it be confidential or otherwise restricted from public access to House of Hope and its agents. I further grant House of Hope or its agents the right to have conferences, including telephone conferences, with outside agencies for the purposes of discussing said information in my file or otherwise obtaining needed information for purposes of meeting the needs and purposes of House of Hope.

Further, I give permission to the case manager and staff of House of Hope to divulge pertinent information to the House of Hope and / or any other staff if they feel the information is needed for health and well-being of me or other residents in the House of Hope. By signing this agreement, I understand that some confidential information may have to be revealed for my benefit or the benefit of others in the house.

Applicant Signature:

Date:

RIGHT TO USE CASE HISTORY

First name

hereby grant House of Hope the right to use my testimony in my case history with House of Hope for purposes of media coverage, special bulletins publications, advertisements, or any other documentary or public coverage of House of Hope and its affiliates. I further recognize that I may be requested to speak at public gatherings, give my testimony, or participate in House of Hope fundraisers, although I may forgo these functions if I deem it necessary. While participation would be appreciated by House of Hope, House of Hope will respect my decisions in these matters.

Applicant Signature:

Date:

SEARCH / ZERO TOLERANCES POLICY

The House of Hope has the right to search all personal belonging. House of Hope will give random urine / drug testing at any given time. Failure to comply will result in immediate dismissal.

Applicant Signature:

Date:

Please check box after reading each point:

I release the House of Hope / North Side Assembly of God from all responsibility, both physical and financial, in the case of accident, injury, illness or other imponderable misfortune.

It is understood that if I damage any property, it is my responsibility to pay the repair costs for the damaged property.

It's also understood that while at the House of Hope, I may participate in various work-study assignments and fundraiser events. Should I be hurt or injured on any of these events, I will not hold the House of Hope / North Side Assembly of God responsible. I understand that I am willingly attending these events as part of the House of Hope transitional home.

Financial Agreement: I agree to pay the House of Hope one-third of the income (net) I may receive while I am a resident. This is called "giving back" to the ministry, so that we can continue to help other ladies.

Refund Agreement: In the event that I leave or am dismissed from the House of Hope, I understand that the money I have already paid to the house is non-refundable.

Transporation Release: As a resident of the House of Hope, I will not hold the House of Hope / North Side Assembly of God responsible in the event of any accident which could result in a non-ministerial vehicle. Non-ministerial vehicles are described as follows:

Staff cars / North Side Assembly Vehicle

Approved volunteers' cars

Residents and / or their family's cars

Food Stamps Agreement: I agree to sign up for Food Stamps while at the House of Hope. I agree to do this so that I can provide for myself until such a time that my income is suitable to meet my needs and I no longer qualify according to the rules and guidelines of Green County FSD.

I understand that I am responsible to provide my own food while at the House of Hope.

I understand that the House of Hope is not a drug recovery program, a medical facility, or a licensed counseling center and does not provide psychiatric counseling or care. The House of Hope is designed strictly as a Transitional Home.

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a resident, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate explusion from the house.

Applicant Signature:

Date:

HoH Staff Signature:

Date: