90 Day Entry Program

True Light Rescue Mission handbook

Part 1

1st Page
Client Personal Information
Check-in Date

MonthDayYear
Date
Check-out Date

MonthDayYear
Date
Name

First NameLast Name
Middle Initial
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age
Date of Birth

MonthDayYear
Date
Social Security #
Occupation
Where were you born?
City State
Are you Presently Homeless?
How Long Homeless?
Driver’s License #
State
State ID Card #
State
Expiration Date for either or
Education ( Select the last year completed)
Describe other training,certificates, or diplomas you have:
Describe yourskills or employment history (what you have done):
Person to be contacted in case of emergency:

First NameLast Name
Relationship:
Home Address:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Marriage Information: Single / Married / Separated / Divorced /Widowed

Complete this section if you have ever beenmarried or have children
Name of Current Spouse:
Age:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation:
Work Number:
Date of Marriage

MonthDayYear
Date
Have you ever filed for divorce?
Do you have any previous marriages?
if yes, how many
Children:
Are you responsible for child support?
If yes, how much & what arrangements havebeen made for your payment responsibilities?
Church Information:
Are you a church member?
Your denomination:
Church Attendance
Church Name:
Pastor’s Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you going to heaven when you die?
If you answered yes, how do you know for sure?
How often do you read your Bible?
Explain any recent spiritual changes in your life.
Family History
Are your parent’s married to each other?
If no, how long have they beendivorced/separated?
Mother’s Name:
Living:
Mother’s Address:
Occupation:
Church Name:
Father’s Name:
Living:
Father’s address:
Occupation:
Church Name:
Who were you closest to as a child?
How would you rate your childhood?
How many brothers and/or sisters do you have?
Does anyone else in your family have addiction?
If yes, please describe: (please don’t use names,just brother, sister, or parent)
Addictions Information

If you are usingdrugs you may be required to check into a detox center before you come.
What addictions do you have?
How long have you used Drugs or Alcohol?
How long have you been clean or detoxed?
Have you tried any other ways or programs toovercome your addictions?
If yes, please list:
Military Information
Have you ever been in the military?
If yes, what branch
Highest rank held
Jobs Held
Were you honorably discharged?
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Part 3

Last Page
Name

First NameLast Name
CONSENT FOR USE OF IMAGE

NORTH CAROLINA; STOKES COUNTY
TRUELIGHT RESCUE MISSION is a religious charitable institution and relies mainly oncharitable donations and contributions for TRUE LIGHT RESCUE MISSION financing. Thus, TRUE LIGHT RESCUE MISSION uses varioustools for fund raising including but not limited to: pictures, brochures,websites, videos, slide shows, pamphlets, and tracks. These various fundraising and informationalmedia do and may contain images of current and past TRUE LIGHT RESCUE MISSION residents.
I ________________ field. the undersigned, understand that TRUE LIGHT RESCUE MISSION uses images of TRUE LIGHT RESCUE MISSION residents AND I AGREE TO THE USE OF MY IMAGE BY TRUE LIGHT RESCUE MISSION AND I UNDERSTAND THAT ALL PHOTOGRAPHS OR VIDEO OF TRUE LIGHT RESCUE MISSION RESIDENTS BECOME THE SOLE PROPERTY OF TRUE LIGHT RESCUE MISSION AND I WAIVE ANY AND ALL CLAIMS WHICH I HAVE OR MAY HAVE IN FUTURE AGAINST TRUE LIGHT RESCUE MISSION RESULTING FROM OR CONNECTED TO THE USE OF MY IMAGE BY TRUE LIGHT RESCUE MISSION. I further understand that I will not be allowed to use such media for my own personal use upon leaving TRUE LIGHT RESCUE MISSION.
RESIDENT
Type your name as your signature
RESIDENT (SIGNATURE) AND DATE
Type your name as your signature
WITNESS AND DATE (STAFF ONLY)
Type your name as your signature
RELEASE OF LIABILITY FOR SHINING LIGHTBAPTIST CHURCH AND ASSUMPTION OF RISK AGREEMENT

NORTH CAROLINA; STOKES COUNTY
SHINING LIGHT BAPTISTCHURCH is a major contributor and benefactor of TRUE LIGHT RESCUE MISSION. As such, SHININGLIGHT BAPTIST CHURCH is heavily involved with TRUE LIGHT RESCUE MISSION. SHINING LIGHTBAPTIST CHURCH provides many benefits and services to TRUE LIGHT RESCUE MISSION residents including, but not limited to: providingresidential and dining space, spiritual direction, pastoring, mentoring, andcounseling.
I ________________the undersigned, do hereby declare that I do desire to be admitted into TRUE LIGHT RESCUE MISSION, and I do desire to participate and become a beneficiary of the TRUE LIGHT RESCUE MISSION program and the benefits and services provided by SHINING LIGHT BAPTIST CHURCH.
I ________________the undersigned, do hereby declare that I understand that TRUE LIGHT RESCUE MISSION is a religious charitable organization which helps persons from various walks of life with various mental and social issues and mental and social problems, some of which have a history of criminal behavior and violence, and that travel to and from work and church or other services is often required, and manual and other dangerous work is required of residents including work with power tools and other dangerous implements in hazardous and often dangerous locations and as such, THE RISK AND/OR THREAT OF LOSS INCLUDING SERIOUS INJURY AND/OR DEATH IS REAL, SUBSTANTIAL, AND SIGNIFICANT.
I ________________the undersigned, in bargained consideration for admittance into TRUE LIGHT RESCUE MISSION and for the services and benefits provided by TRUE LIGHT RESCUE MISSION AND/OR SHINING LIGHT BAPTIST CHURCH, do hereby assume all risks, both known and unknown, even if arising from the negligence of those persons released from liability below, and I assume full responsibility for my participation in the TRUE LIGHT RESCUE MISSION program, and I do hereby release, discharge, and agree to hold harmless SHINING LIGHT BAPTIST CHURCH and SHINING BAPTIST CHURCH’s board members, trustees, officers, officials, pastors, deacons, members, employees, volunteers, agents, and representatives from and against any and all demands, claims, and actions at law or equity which I, my estate, heirs, assigns, or representatives might have now or in future against SHINING LIGHT BAPTIST CHURCH and SHINING LIGHT BAPTIST CHURCH’s board members, trustees, officers, officials, pastors, deacons, members, employees, volunteers, agents, and representatives, without limit and without regard to the cause or causes thereof, or the negligence of any party or parties, including the negligence of SHINING LIGHT BAPTIST CHURCH, whether such negligence be sole, joint, several, or concurrent for injury, illness, death, damage to property, loss, or expenses of any and all kinds, arising out my association with TRUE LIGHT RESCUE MISSION and/or SHINING LIGHT BAPTIST CHURCH or in connection with TRUE LIGHT RESCUE MISSION and/or SHINING LIGHT BAPTIST CHURCH. Men excepting those claims arising from the gross negligence and/or wanton misconduct of TRUE LIGHT RESCUE MISSION and/or SHINING LIGHT BAPTIST CHURCH.
I ________________the undersigned, declare that I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTANDING ITS TERMS, AND I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
RESIDENT
Type your name as your signature
RESIDENT (SIGNATURE) AND DATE
Type your name as your signature
WITNESS AND DATE (STAFFONLY)
Type your name as your signature
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Part 2

2nd Page
Name

First NameLast Name
Legal Information
Have you ever been arrested or in jail?
No If yes, where:
Charges:
Time Served:
(If on probation must give following information)
Name of Your Parole/Probation Officer:
PO’s Phone #
Please enter a valid phone number.Format: (000) 000-0000.
PO’s Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
A letter of Acceptance can be issued to the Probation Officer if requested by the PO. I must have a letter from the Probation Officer stating that you have his permission to attend our program.
Do you have any pending court cases?
If yes, Give details
Are you a registered sex offender?
if yes must be authorized by member of Executive Staff.
Are you court ordered to not be around children?
Medical History
Height
Weight
Hair color
Eye color
Do you have any medical problems?
If yes, please explain and give your Doctor’s name:
Are you currently on any medications?
If yes, please list:
Do you have any allergies?
List any medical allergies
Date & Place of your last medical exam:
Have you ever been treated for Mental Illness?
No If yes, please list results:
What Medications were prescribed for your MentalIllness and When?
Check-Out Date:

MonthDayYear
Date
Supervisor:
Reason for Check-Out:
Eligible return date:

MonthDayYear
Date
Please read each page of the Admission Rules & Regulations and initial each item below.
Check-in & Medicine Times
Visitation
Home Pass
General Dress Code
Dress Code For Church Services
Meal Procedures
Phone Policy
General Rules & Time Schedule
Nicotine/ Smoking Policy
On-Site Work Policy
Off-Site Work Policy
Personal Finance Policy
Storage Policy
Fraternization Policy
Fighting Policy
Check-out Policy
Supervisor Signature
Type your name as your signature
Date

MonthDayYear
Date
I, ______________________. agree to fulfill the following contract terms with True Light Rescue Mission.
Things you may be asked to leave the mission for are as followed:

1. Profanity (No cursing) 2 . Fighting 3. Theft (Anything that does not belong to you money, clothes, books, ect.) 4. Lying 5. Lude Acts (Any sexual activity that goes against the Bible) 6. Failing a drug test (tests may be given at any point and time by staff) 7. Defiant behavior towards the staff (arguing with staff or residents) 8. Refusing job assignment (will be given out after chapel each morning) 9. Not signing a write-up (action taken after a rule is broken) 10.Three (3) write-ups in thirty (30) days 11. Walking off the mission property 12. Not returning from home pass as scheduled (unless approved by supervisor) 13. Fraternizing 14. Starting a new romantic relationship in the first six months 15. Smoking 16. Not turning medicine/prescriptions into office. (This includes prescriptions in your possession)
Resident’s Signature
Type your name as your signature
Witness:
Date:

MonthDayYear
Any resident allowed to check back in early must have authorization by Executive Staff and signed and dated by staff member.
Signature:
Type your name as your signature
Date:

MonthDayYear
Date
CONTRACT FOR TREATMENT AND RELEASE OFLIABILITY AND ASSUMPTION OF RISK AGREEMENT

NORTH CAROLINA; STOKES COUNTY
I, __________________ the undersigned, do hereby declare that I have: examined the TRUE LIGHT RESCUE MISSION facilities, read the TRUE LIGHT RESCUE MISSION handbook, been made fully aware of all duties and obligations required of me by TRUE LIGHT RESCUE MISSION, and that I know the nature of all activities and travel at TRUE LIGHT RESCUE MISSION, and I do desire to be admitted into TRUE LIGHT RESCUE MISSION, and I do desire to participate and become a beneficiary of the TRUE LIGHT RESCUE MISSION program.
I, __________________the undersigned, do hereby declare that I understand that TRUE LIGHT RESCUE MISSION is a religious charitable organization which helps persons from various walks of life with various mental and social issues and mental and social problems, some of which have a history of criminal behavior and violence, and that travel to and from work and church or other services is often required, and manual and other dangerous work is required of residents including work with power tools and other dangerous implements in hazardous and often dangerous locations and as such, THE RISK AND/OR THREAT OF LOSS INCLUDING SERIOUS INJURY AND/OR DEATH IS REAL, SUBSTANTIAL, AND SIGNIFICANT.
I, __________________the undersigned, in bargained consideration for admittance into TRUE LIGHT RESCUE MISSION and for the services and benefits provided by TRUE LIGHT RESCUE MISSION, do hereby assume all risks, both known and unknown, even if arising from the negligence of those persons released from liability below, and I assume full responsibility for my participation in the TRUE LIGHT RESCUE MISSION program, and I do hereby release, discharge, and agree to hold harmless TRUE LIGHT RESCUE MISSION and TRUE LIGHT RESCUE MISSION’s board members, trustees, officers, officials, pastors, employees, volunteers, agents, and representatives from and against any and all demands, claims, and actions at law or equity which I, my estate, heirs, assigns, or representatives might have now or in future against TRUE LIGHT RESCUE MISSION and TRUE LIGHT RESCUE MISSION’s board members, trustees, officers, officials, pastors, employees, volunteers, agents, and representatives, without limit and without regard to the cause or causes thereof, or the negligence of any party or parties, including the negligence of TRUE LIGHT RESCUE MISSION, whether such negligence be sole, joint, several, or concurrent for injury, illness, death, damage to property, loss, or expenses of any and all kinds, arising out my association with TRUE LIGHT RESCUE MISSION or in connection with TRUE LIGHT RESCUE MISSION excepting those claims arising from the gross negligence and/or wanton misconduct of TRUE LIGHT RESCUE MISSION.
I, __________________the undersigned, declare that I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTANDING ITS TERMS, AND I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
RESIDENT (PRINTED NAME)
Type your name as your signature
RESIDENT (SIGNATURE) AND DATE
Type your name as your signature
WITNESS AND DATE
REQUEST FOR MEDICAL INFORMATION AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION

NORTH CAROLINA; STOKES COUNTY
I, the undersigned, do hereby request and authorize True Light Rescue Mission, and/or any treating physician, hospital, and/or clinic who has treated or examined me to release copies of all medical reports and/or medical information pertaining to my present or past condition (s) of health and to forward copies of the same if so requested directly to and/or discuss via oral communication and/or correspond with:
True Light Rescue Mission PO Box 138Sandy Ridge, NC 27046276-229-5898

I, the undersigned, authorize you to furnish the True Light Rescue Mission all medical information so requested as the same pertains to treatment of drug or alcohol use, HIV, mental illness, and any other information so requested by TRUE LIGHT RESCUE MISSION. I, the undersigned, because of the close living quarters at the True Light Rescue Mission and for the health and welfare of my fellow residents, agree to make the requested information available to the staff of the True Light Rescue Mission. I, the undersigned ,understand that the information disclosed or used pursuant to this Request/Authorization is subject to re-disclosure and the information obtained may no longer be protected under the terms of this authorization as to my right of privacy. I, the undersigned ,understand and agree that this Request/Authorization is voluntary and shall be valid for a period of two (2) years from the date of its execution. I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do so it will not have any affect on any actions taken before there vocation was received. I, the undersigned, further agree, affirm, and stipulate that a facsimile or copy of this request and/or authorization to release medical information and my signature is as valid as an original.
Resident(Printed) Name
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Social Security Number
Resident Signature
Type your name as your signature
Date

MonthDayYear
Date
Witness Signature (STAFF ONLY)
Type your name as your signature
Date

MonthDayYear
Date
CONSENT FOR DRUGTESTING AND SEARCH OF PERSON AND PROPERTY

NORTH CAROLINA; STOKES COUNTY
TRUE LIGHT RESCUE MISSION isresidential rehabilitation center that helps men with addiction and othersocial problems by providing spiritual direction and employment assistance.TRUE LIGHT RESCUE MISSION does notpermit the use of tobacco, alcohol, or drugs among TRUE LIGHT RESCUE MISSIONresidents. To enforce this policy TRUE LIGHT RESCUEMISSION reserves the right to drug test and/or search the person and/or propertyof TRUE LIGHT RESCUE MISSION residents at any time during their stay at TRUELIGHT RESCUE MISSION.
I, __________________the undersigned, understand that I may be required to give urine samples randomly for drug, alcohol, and/or nicotine testing, and I AGREE TO SUBMIT TO THAT TESTING. I understand that refusal to be tested or a positive result will carry serious consequences, including the notification of the probation or parole officer and/or dismissal from this mission. I also understand that I must quit the use of all tobacco products upon entry into TRUE LIGHT RESCUE MISSION.
I, __________________the undersigned, understand that I may be required to submit to the search of my person or property at any time, and I AGREE TO SUBMIT TO ANY SEARCH OF MY PERSON OR PROPERTY. I understand that refusal to be searched will carry serious consequences, including the notification of the probation or parole officer and/or dismissal from TRUE LIGHT RESCUE MISSION. I further understand that such notification may result in my: unemployment, loss of benefits, prosecution, arrest, confinement, incarceration, imprisonment, and/or other loss of liberty and/or loss of other various property and/or personal interests.
RESIDENT (PRINTED NAME)
Type your name as your signature
RESIDENT (SIGNATURE) AND DATE
Type your name as your signature
WITNESS AND DATE (STAFF ONLY)
Type your name as your signature
CONSENT FORBACKGROUND CHECK AND WAIVER OF PRIVACY FOR GENERAL BACKSGROUND INVESTIGATIONS

NORTH CAROLINA; STOKES COUNTY
TRUE LIGHT RESCUE MISSION works with many men withcriminal records and as such TRUE LIGHT RESCUE MISSION needs to know thecharacter and nature of applicant’s respective histories and therefore reservesthe right to background check and take other appropriate measures to assess theTRUE LIGHT RESCUE MISSION applicant’s or TRUE LIGHT RESCUE MISSION resident’sneeds and/or problems.
I, __________________the undersigned, understand that TRUE LIGHT RESCUE MISSION may confirm through Megan’s Law and/or public record if I am a registered sex offender, and that TRUE LIGHT RESCUE MISSION may also do a background check and take any and all other investigative measures TRUE LIGHT RESCUE MISSION may deem appropriate to assess my background and character at any time prior to and/or during my stay at TRUE LIGHT RESCUE MISSION.
I, __________________the undersigned, understand that if TRUE LIGHT RESCUE MISSION discovers anything in TRUE LIGHT RESCUE MISSION’s investigation including, but not limited to, outstanding warrants, the appropriate law enforcement agency and/or authority will be promptly notified and that such notification could result in my: unemployment, loss of benefits, prosecution, arrest, confinement, incarnation, imprisonment, and/or other loss of liberty and/or loss of other various property and/or personal interests.
RESIDENT (PRINTED NAME)
Type your name as your signature
RESIDENT (SIGNATURE) AND DATE
Type your name as your signature
WITNESS AND DATE (STAFF ONLY)
Type your name as your signature
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90 Day Entry Program

Client Personal Information

Marriage Information: Single / Married / Separated / Divorced /Widowed

Church Information:

Family History

Addictions Information

Military Information

CONSENT FOR USE OF IMAGE

RELEASE OF LIABILITY FOR SHINING LIGHTBAPTIST CHURCH AND ASSUMPTION OF RISK AGREEMENT

Legal Information

Medical History

Things you may be asked to leave the mission for are as followed:

Any resident allowed to check back in early must have authorization by Executive Staff and signed and dated by staff member.

CONTRACT FOR TREATMENT AND RELEASE OFLIABILITY AND ASSUMPTION OF RISK AGREEMENT

REQUEST FOR MEDICAL INFORMATION AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION

True Light Rescue Mission PO Box 138Sandy Ridge, NC 27046276-229-5898

CONSENT FOR DRUGTESTING AND SEARCH OF PERSON AND PROPERTY

CONSENT FORBACKGROUND CHECK AND WAIVER OF PRIVACY FOR GENERAL BACKSGROUND INVESTIGATIONS

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