Redemption House

Application / Contract

Complete every applicable field. The submitted form will be emailed to Redemption House staff.

Application process

Complete this application and submit it through this form. It will be emailed to chuck@tbvme.com.
Complete a Zoom or in-person assessment with Redemption House staff.
Upon approval, arrange the date and time of arrival with staff.
Contact Chuck Madden at (941) 545-4360 with questions.

Source note: First & Last Weeks rent due upon arrival and is Non-refundable.

1. Applicant information

Date of application

Referred by

Last name

First name

Middle initial

Phone

Sobriety date

Drug of choice

Name of insurance company

Member ID number

Age

Date of birth

Height

Weight

Hair

License or state ID number

Marital status

Children

Car

Yes No

Car make

Car model

Car license number

Emergency contact

Emergency contact phone

Relationship

3. Rent, notice, belongings, and goals

Two-week notice: Upon 2 weeks notification of intent to leave, the "Last week's rent", paid upon entrance, will be applied to your last week of occupancy.

Rent due date: Rent is due Friday by 6pm to Redemption Staff or via Redemption Portal.

Weekly rent selection

$300 multi $350 single

The source form states: $300 multi or $350 single Plus $50 /mnth electrical fee for mini fridge (if approved). New Rates Effective October 15, 2024.

Initials acknowledging the rent selection and mini-refrigerator fee

I understand the two-week notice, rent due date, selected weekly rent, and possible approved mini-refrigerator electrical fee stated above.

I understand that if I leave Redemption House for any reason, I will have seven days to pick up my personal belongings. After that time, anything left behind will become property of Redemption House and be considered abandoned.

Where do you see yourself?

In 6 months

In 12 months

In 18 months

What do you hope to gain from residing at Redemption House?

4. Application / contract statement

Name in the contract statement

This completes the source statement that begins: I, [name], state that...

I, [name entered above], state that I have responded accurately & honestly to all of the information requested in this application. I state that my intentions are to remain abstinent from alcohol & drugs of any kind. I state I am responsible enough to manage my own medications & understand that Redemption House reserves the right to inspect prescription bottles for pill count & accuracy of administration and to enter & inspect my room at any time. I state once again that I have neither been charged, nor convicted of arson, or any sexual related crimes. I state that I will abide by all house rules & perform my daily chores as assigned. I state I will meet all probationary and/or parole requirements. I state that I understand my residence at Redemption House makes me a member of the surrounding communities and I will conduct myself in an orderly fashion; living within the laws of the City and Commonwealth as they are written.

I understand that Redemption House staff may contact my probation officer at any time to update and share information and notify if I fail a urine drug test, or am asked to leave. Also, I understand I am required to give two (2) weeks notice in writing to chuck@tbvme.com prior to moving out.

I understand that Redemption House is my home and I have the same responsibilities that I would have as if I was living at home. This includes being respectful towards others, picking up after myself, paying my rent on time, and volunteering my time as designated by Redemption House team. Also, I will not take anything that does not belong to me, including food, clothing, or any other item. REDEMPTION HOUSE is a ZERO TOLERANCE COMMUNITY. NO Alcohol/Drugs, or mind altering substances will be tolerated. If I am to leave the house, I will have 7 days to pick up my belongings and will not allowed on site until a minimum of 180 days has passed and a conduct interview by Redemption House staff. Readmittance or participation on Redemption House property will be at the sole discretion of Redemption house staff and may be unilaterally withheld. After 7 days, I understand that any items left behind become property of Redemption House.

I have read, understand, and agree to the complete Application / Contract statement above.

Signature of resident - type your full legal name

Signature date

Print name

I intend the typed name above to serve as my electronic signature for this application.

5. Resident participation and safety policies

Resident Participation Policy

As part of our resident's recovery process, we strive to involve residents in governance of the house. To reach this goal/standard resident will create some rules/procedures and guidelines in consultation with the operator. Residents, not staff, will implement and enforce resident created rules/procedures. For example, house chores.

Safety Policy

To ensure our property is maintained in a safe manner we will install and maintain:

Functional smoke detectors in all bedroom areas and elsewhere required by local code.
Functional carbon monoxide detectors on all floors and elsewhere required by code.
Functional fire extinguishers in every kitchen in a clearly marked location.

We will verify that all detectors are present and are in good order monthly and will replace batteries at least once per year. All smoke detectors will be replaced at least once every ten years. Fire and other emergency evacuation drills take place regularly and are documented.

I have read and understand the Resident Participation Policy and Safety Policy.

For Redemption House use only

These fields are intentionally disabled on the public application and appear as blank staff fields in the emailed copy.

Approved / denied by house manager or director

Date

If denied, reason for denial

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Redemption House Application

Application / Contract

Application process

List three positive things about yourself

List three things about yourself needing improvement

Where do you see yourself?

Application process

List three positive things about yourself

List three things about yourself needing improvement

Where do you see yourself?

Electronic submission