Full Intake Form Please fill out the fields below to start joining the David's House community. Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Drivers License #StateExpires Date Format: MM slash DD slash YYYY License Plate #Vehicle MakeVehicle ModelPhone NumberEmail* Emergency Contact* First Last Relationship*Emergency Contact Phone Number*Employer*Employer Phone Number*Do you have health insurance?*YesNoInsurance NamePolicy #Medical Conditions / AllergiesPrescription MedicationsNote that narcotic medications are not allowed / You must provide a lockboxHow long have you been sober?Drug(s) of choiceWhich 12 step meetings do you attend?(AA, NA, CA, etc)Sponsor NameSponsor's Phone NumberHave you ever lived in a Sober Living Home?*YesNoIf yes, which one?*Are you involved in any legal action?*YesNoIf yes, please explain*Are you required to register as a sex offender?*YesNoAre you ever been convicted of arson?*YesNoAre you ever been convicted of a felony?*YesNoSource of income?Salary (weekly/monthly)Weekly Fee + $100 intake feeDavid’s House Sober Community is a recovery home which, we reserve the right to impose consequences without prior notice or refund of fees, of any resident member who is found to be: Using alcohol or drugs; Engaging in disruptive behavior; or In default of payment of weekly fee. All residents of David’s House Sober Community are members of our recovery home. You do NOT have renter’s rights or any rights of tenants pursuant to the Colorado Property Code, and expressly waive any such rights in exchange for membership privileges. I have read the above notice and understand that I am applying for membership of David’s Home Sober Community as a member of a recovery home. I agree to abide by the responsibilities requirements of the house and fully subject myself to the rules of the home, which include periodic / random drug and alcohol testing. I understand that I am subject to consequences if any of the following occur: 1) I use alcohol or drugs (other than prescribed/non-narcotic medications); 2) I engage in disruptive behavior (continued patterns of irresponsible behavior are considered disruptive behavior); 3) I fail to pay my weekly fee. In understand that my deposit and fees will be forfeited. By signing below, I certify that the information contained in this application is true. I have read and understand the David’s House Sober Community house rules and polices. I understand and accept the above conditions set forth for membership to David’s House Sober Community, and agree to abide by said conditions should I be selected as a member resident.Consent* I agree to this website and David's House privacy policy.CommentsThis field is for validation purposes and should be left unchanged.