River Housing Application

640 Griffin St.

Fall River, MA 02724

774-704-5501

HOUSE RULES PLEASE READ BEFORE PROCEEDING

RESIDENT AGREEMENT

RESIDENT RIGHTS

First & Last Name

Email Address

Date of Birth

Recent Address

City, State, Zip

Best number to contact you

Drug(s) of choice & date of last use

Have you completed treatment for alcohol/drugs?

Current employer & Contact Info / Position / Start Date . If you are a student, provide name of institution & field of study.

If you have health insurance, provide ID and subscriber info

Current Medicatons if applicable

You will be required to provide any arrests or legal issues upon being interviewed. If you are on probation/parole, list the name of your officer. If you are in drug court, provide length of sentence.

Do you have any outstanding warrants? If yes, provide info

If you have children, list ages, whether you have custody, and if there is DCF involvement

List any of the following if applicable: Recovery Coach, Recovery Support Navigator, Therapist, Nurse, Any other Health Provider, and Past Treatment Centers:

Are you willing to sign a release of information form?

Do you give permission to run a CORI check?

Affirm that you will review & abide by the "House Rules" (click link on top of this page)and that $250.00 per week must be submitted every Friday by 4:00 PM

Emergency Contact: Name, relationship, Address, Phone #

Please type your signature below affirming that you have answered all questions honestly, that you have read the 'House Rules' and understand violation could result in expulsion, and any use of alcohol & illegal drugs is prohibited. By accepting these terms, I waive all rights under MA landlord-tenant law, and release River Housing and its principals from the normal due process requirements.

Thanks for submitting!