Application Form – The Official Website of Lac Courte Oreilles

First Name

Last Name

Birthdate

Best number to reach you

Current Address

Emergency Contact Name

Relationship

Emergency contact number

Secondary phone number (if needed)

Sobriety Date

What is your expected move-in date?

Have you ever lived in a sober living home before?

Yes No

Are you currently enrolled in Drug Court?

Yes No

Do you have any criminal convictions? If, Yes, please explain below

Yes No

Are you or will you be taking any prescribed medications? If yes, please list all prescribed medications

Yes No

If Yes, list medications here:

How are you planning on paying for rent?

Are you currently in a Treatment Facility?

Yes No

If yes, list the Treatment Facility here

Counselor's name and contact info (if applicable)

A $XX move-in fee is due on move in.

Are you willing to commit to sober living for XX months?

Yes No

Please list why you want to be accepted to the Endazhi-noojimong now.

I have read the above notice and understand that I am applying for entrance to Endazhi-noojimong Sober Living as a member of a recovery home. I agree to abide by the responsibilities and requirements of the house and fully subject myself to the rules of the home, which include periodic/random drug testing.I understand that I am subject to immediate expulsion from the home if any of the following occur: 1) I use alcohol or drugs (other than prescribed medications); 2) I engage in disruptive behavior (continued patterns of irresponsibile behavior are considered disruptive behavior); 3) I fail to pay my monthly dues. I understand that if I leave voluntarily I will submit a 30 day verbal notice to vacateto the house manager and/or program director. By signing below, I certify that the information contained in this application is true. I have read and understand the Endazhinoojimong rules and policies. I understand and accept the above conditions set forth for membership to Endazhi-noojimong rules, and agree to abide by said conditions should I be selected as a resident.

Enter Name as Signature

Lac Courte Oreilles

Band of Lake Superior Ojibwe

ONLINE APPLICATION

APPLICATION