VII. Applicant Statement: 1. I understand that, as part of the application process, I must be agreeable to provide military and medical documentation, including, but not limited to: DD214, blood work (including pregnancy test for women), urine drug screen, and tuberculosis screening (PPD). 2. I understand I must provide Veteran’s Haven North with my contact information and communicate any changes to that information, immediately, in order to facilitate my admission. 3. I understand that if I am accepted to Veteran’s Haven North, I would be provided with copies of the rules/regulations and policy and procedures, which I will be expected to follow. 4. I understand that if I am accepted to Veteran’s Haven North, I would work with the staff to establish and adhere to a treatment plan. 5. I understand that, as a resident at Veteran’s North, I would be assigned collective duty assignments/ chores related to the function and daily operation of the home. 6. I understand that I will need to sign release of information forms for healthcare providers, parole officers, etc. for coordination of my treatment plan. 7. I understand that, if I fail to answer application questions honestly and accurately, my admission and/or residency at Veteran’s Haven North may be affected. 8. I understand that, should I be accepted for residency at Veteran’s Haven North, my failure to meet the aforementioned expectations may also affect my residency there. ___________________________________________ (Applicant Signature)
VII. Applicant Statement: 1. I understand that, as part of the application process, I must be agreeable to provide military and medical documentation, including, but not limited to: DD214, blood work (including pregnancy test for women), urine drug screen, and tuberculosis screening (PPD). 2. I understand I must provide Veteran’s Haven North with my contact information and communicate any changes to that information, immediately, in order to facilitate my admission. 3. I understand that if I am accepted to Veteran’s Haven North, I would be provided with copies of the rules/regulations and policy and procedures, which I will be expected to follow. 4. I understand that if I am accepted to Veteran’s Haven North, I would work with the staff to establish and adhere to a treatment plan. 5. I understand that, as a resident at Veteran’s North, I would be assigned collective duty assignments/ chores related to the function and daily operation of the home. 6. I understand that I will need to sign release of information forms for healthcare providers, parole officers, etc. for coordination of my treatment plan. 7. I understand that, if I fail to answer application questions honestly and accurately, my admission and/or residency at Veteran’s Haven North may be affected. 8. I understand that, should I be accepted for residency at Veteran’s Haven North, my failure to meet the aforementioned expectations may also affect my residency there. ___________________________________________ (Applicant Signature)
VHN-Application-for-Admission-Form.docx