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    Personal Information

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    Contact Information

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    Emergency Contact

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    Drug/Alcohol & Treatment History

    Substances Abused *

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    Previous Sober Living *

     

    Legal Information

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    Registered Sex Offender *

    If Yes Above, Please Describe

     

    Medical Information

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    Acceptance & Verification

    I hereby certify that the information above is true and accurate and that Independence Lodge may utilize the information in rendering a decision on my acceptance into the sober living program they facilitate. *

    I'm Human *