Admittance and Evaluation Indemnity form
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- Poppy Ford
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1 1 Admittance and Evaluation Indemnity form This needs to be completed before an individual is admitted We are a life skills centre that provides a learning environment facility PLEASE NOTE!!! We are not a medical facility no medical personnel and no medical facilities are available We cannot cater for severely challenged persons both medical and mental scenarios We are not a lock-up facility individuals may leave at any time We do not cater for juveniles and we are currently a co-ed facility Please supply all necessary information in full. Please read all the rules pertaining to our Centre. Surname: First names: Alias: ID No: Proof of ID: Copy of ID: DOB: Reason for admittance: Age: Next of kin: Contact detail: Brought in by: Relationship: Cell no: Additional contact no: Correspondence details: Referred by: Religion preference: Please agree to and comply with the following: All persons enter the admittance and evaluation facility at their own risk. Entirely and fully at one's own risk! Neither management, landowner nor staff will be liable in any way.
2 2 All new persons must supply a verifiable identity and/or allow for police check. All persons must hand in all medication and make a full disclosure of medical conditions. Medication will be dispensed as prescribed. We strongly recommend a doctor's report and we accept no liability in the event of health problems or death. Medical information, allergies and concerns: Any cost incurred for any reason are the responsibility of the applicant. These include drug tests if any needed, ambulance cost if called, travelling costs etc. No banned substances and/or items allowed: These include Any narcotic drug and its paraphernalia, Alcohol, alcohol bottles, cough mixture, mouth rinses, meths, yeast and/or anything used to make alcohol Dagga in any form Any readily abused substance: Grandpa, hormones, steroids, etc: Medication with codeine and/or any medication with derivatives of narcotics Animals and/or pets Firearms and other weapons Tattoo paraphernalia Pornography of any form Noise producing equipment Personal cell phones for the first 6 weeks, your cell phone will be handed back to you after your evaluation period of the first 6 weeks Cash and any bank card's :credit and/or debit cards All valuables should be left with family or friends at there own risk. Those who arrive with valuables should hand in these valuables for safe keeping at there own risk. All banned items and substances must be handed in or disposed of on entering our premises. Persons and/or their belongings may be searched at any time for any of the above items. Note: We deal with a variety of persons. Keep all things under lock and key. We do not accept responsibility for items lost or stolen. Items handed in for safe keeping:
3 3 Note: 1. That it is not permissible at any time to use banned substances on the property of Break free Christian life skill centre. 2. That it is not permissible at any time to use banned substances whilst off the property whilst at admittance or as a resident of our community. 3. That I will be randomly tested for alcohol and drugs using a test indicator. These test may be given to the SAPS or parole officer who may press charges. 4. That I will not be able to return to Break free Christian life skill centre should I be found to be in possession of alcohol or drugs or should the test show positive. 5. That should it be found that I was aware of anyone intending to use, or using banned substances and did not report this, I shall be asked to leave immediately. 6. That should I be asked to leave for withholding information, dishonesty on the application, etc, I will not be eligible for re-admittance to the Break free Christian life skill centre community with in two years after I have left. 7. That I am currently not withholding any information pertaining to any illegal substances at Break free Christian life skill centre. 8. That the use of prescribed medication is under a doctors care and permissible at the discretion of Break free Christian life skill centre History of applicant: Were you at a rehab before? Yes: No: Please provide a list of other rehabs where you have resided before with dates and why you left there: Any objections to attending our churches, devotions, meetings, teaching, etc: What are your hopes, dreams and/or ambitions? What are you expecting from Break free Christian life skill centre?
4 4 Brief description of financial status: How much have you agreed to financially contribute? R Monies paid?r Any other assistance promised: Do you have any family, friends, companions, etc. residing at our centre? Please note and agree to the following: Historically we have had all sorts here. In order to prevent negativity, any banned substance used, trouble makers, etc. we emphasize an agreement before one is allowed in admittance. Your signature is needed to include the following: Any person leaving the premisses without proper procedure may be refuse access to return. If they leave any belongings behind, these will be considered abandoned if not collected within 7 (seven) days. We do not forward any belongings to individuals. If they are refused access to return, then family must collect there goods within 7 (seven) days. We accept NO responsibility for anyones belongings abandoned or otherwise. Any person causing any trouble in any way may be told to leave the premises the same day providing it is not close to sunset or dark. Any person breaking our rules in any way may be told to leave the premises the same day providing it is not close to sunset or dark. Any person causing trouble in any way and/or breaking the rules in any way that may be substance related and/or violent and/or a security risk in any way may be told to catch a lift with police, security, bakkie, etc. to the police station at any hour if necessary. Any money paid at admittance or during your stay at Break free Christian life skill centre is NON-REFUNDABLE. Please note we have strict rules. Make sure that you read and understand all the rules Can you read & write? Level of education: Trades or training:
5 5 Are you here by your own free will: Family? Work stipulations? Other? If by courts, which court? Liaison person: Tel: Are you here on parole? Parole officer: Tel: Are you an addict? Are you totally clean from drugs? Will a urine test be clean? Special reference to psychotics, schizophrenics, bi-polar etc. We are not a Psychiatric facility. Are there any metal disorders that we need to know about? Mental institutions? When? Medications currently used: Special reference to fugitives, illegal migrants and/or any person who cannot positively identify themselves or any person who we perceive may in any way cause suspicion as to there true identity: At times we request a police check on a person's identity. Any objection? We are not prepared to hide or conceal any person's whereabouts for any reason. Are there any outstanding warrants, fines, etc? Special reference to the severely physically challenged. Sorry - our terrain is not suitable for you.
6 6 Are there any details on the indemnity form which you wish to add or alter in any form? Any additional comments? I understand and agree to the above terms and conditions and indemnify Break free Christian life skill centre or any person associated with this centre of any liability as stated herein. I declare that I am of sound mind and that I am not intoxicated in any way. Signature: Date (in full): ID: DOB: Address: Witness by the person who brought you here: Signature: Tel no: Admitted by: Signature: Date:
7 7 Separate form for any form of addictions Surname: Name: Alias: Age: Id No: Proof of ID? Copy of ID? DOB: Why have you come to Break free Christian life skill centre? Drug of choice: Are you fully detoxed with no need of any medical or further treatment? I last used the following substances on the respective dates: HEROIN COCAINE LSD TIK/CRYSTAL METH ECSTACY DAGGA AMPHETAMINES ALCOHOL GLUE/OTHER INHALANTS KETAMINE ABUSED STEROIDS ABUSE PRESCRIPTION MEDS OTHER I confirm that I have read the above, that I understand the above and that I have been informed of the above. Further I am of sound mind and clear conscience. SIGNED: NAME DATE IN FULL
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