Admittance and Evaluation Indemnity Form

Transcription

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!!! 1. We are a co-ed facility. 2. We are not a medical facility. 3. No medical personnel and no medical facilities are available. In an emergency the resident will be takento the clinic. 4. We will do clinic days on the 30 th of each month for those who have no medical aid and need chronic medicines or to see a doctor. 5. Residents who have medical aids must arrange with their parents/sponsors to collect their medication and bring it on a visiting day. Should we be requested to collect any private medication or visit a doctor a charge will be levied for petrol. We are a distance from town. 5. We do not cater for persons who are severely challenged mentally or physically. 6. We do not cater for juveniles. 7. We are NOT A LOCK-UP facility, residents may leave at any time. Should a resident be here by Court Order (Section) and leave. The police will be notified and the resident will be arrested and in all probability be required to complete their time in prison. 8. We cannot hold a space for any one person for longer than 24 hours unless a non refundable deposit is paid equal to half the admittance fee. 9. Bank charges on physical deposits will be debited to residents account.. The Admittance Fee will be paid on admittance, and the fee for the following month will be paid on the last day of the date of admittance. For instance admitted say on 15 April the next payment for May will be on the last day of April. Please discuss the admittance fee and contribution with Carl or Angela. There is a list of needs for residents, however, if you are unable to supply any of them please also speak to Carl or Angela

2 2 Please supply all necessary information in full. Please read all the rules pertaining to our Centre. Surname: First names: Also known as Identity number : Copy ID yes/no Date of Birth Age South African Citizen: yes/no Reason for Admittance Next of kin: Contact detail: Brought in by: Relationship: Cell no: Additional contact no: Correspondence details: Referred by: Christian: yes/no Please agree to and comply with the following: All persons enter the admittance and evaluation facility at their own risk. Entirely and fully at their own risk! Neither management, landowner nor staff or any trustee will be liable in any way for any reason whatsoever. 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 Resident and/or sponsor. 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, or pepper spray 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 Cell phones Laptops, tablets or any kind of technological equipment NO PERSONAL CELL PHONES. WE HAVE A CELL PHONE FOR INCOMMING CALLS ONLY TUESDAY AND THURSDAY BETWEEN 19H00 AND 20H00 AND SUNDAY AFTERNOONS. CALLS ARE RESTRICTED TO 10 MINUTES EACH AND

3 3 ONLY TWO NOMINATED PERSONS MAY CALL. Nominated persons who may call All valuables should be left with family or friends at their own risk. Those who arrive with valuables should hand in these valuables for safe keeping at their 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: 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 may 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 within 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 rehabilation centre before? Yes: No: how many Please provide a list of other rehabilitation centres/halfway houses, where you have resided before with dates and why you left there: Any objections to attending our churches, devotions, meetings, Christian teaching, etc: What are your hopes, dreams and/or ambitions? What are you expecting from Break Free Christian Life Skill Centre? Brief description of financial status:

4 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 premises without proper procedure may be refused consent 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 being disrespectful, not working, using, drinking alcohol, stealing, swearing and in general a distraction in any way to staff or other residents - may be told to leave the premises the same day. The said person will be delivered to the nearest police station should their family refuse to collect them. Otherwise the police will be called to collect them. Those that are at Break Free under a legal Section will then be taken into custody by the police and will do the rest of their time in prison. The same rules apply to those wanting to leave because of a decision they have made. Any money paid at admittance or during your stay at Break Free Christian Life Skill Centre is NON-REFUNDABLE regardless of whether the admitted person leaves in two or three days. This money is forfeited. Depending on circumstancecs should you have been given a discount on the fee. The discount between the actual fee and what you paid, becomes payable and the amount you paid may be deducted from the then total amount. We shall then look to your sponsor for payment of this difference.. Full fees are R 4 500,00 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: 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? 4

5 5 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? Should you have a court date your sponsor is required to collect you and make sure you go to Court and return to ourselves afterwards. We shall hand you a letter in mitigation if we find it fitting. Special reference to the severely physically challenged. Sorry - our terrain is not suitable for you. 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:

6 6 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 Please further note Residents will be taken to clinic once a month for those who may be ill or need repeat prescriptions, unless its an emergency. Should you have a private medical aid it is up to your sponsor to get you to a doctor and/or to bring your medication when visiting. There are NO tuck shop runs. Please ask your sponsors to bring you whatever you need in the way of cigarettes, coffee and luxuries. This teaches the resident to make do. We do supply coffee, tea, sugar, milk and juice besides the meals. However, we find that recovering addicts drink many cups per day. There will be no asking for cigarettes from each other. Break Free used help out but will no longer do so due to residents taking advantage. 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

7 DATE IN FULL 7