Application

Do you want an opportunity to live in a Daffodil Place™ house? Please fill out the application below. You can use your cell phone or computer or print the PDF form, complete it by hand, and send it to us.

We do limit all previously incarcerated individuals to non-violent offenders, and all residents must have completed a recovery program or be working with a sponsor and be working toward an independent, sober-free life.

Upon joining our residence, all residents must complete a resident agreement that lists emergency contacts, responsible financial parties, a relapse recovery plan, an agreement to abide by house rules, and an active commitment to returning to a productive, independent, sober life.
All residents must be in School, have a job, preferably full-time, or a plan approved by their sponsor detailing their planned progress toward an independent, sober-free life.

Daffodil Place™ Residential Application

Daffodil Place™ Residential Application

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Option 1: Complete the form online and submit it. The form will be uploaded to Google Docs and emailed to the applicant as a PDF.

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Option 2 – Download the application pdf to be completed and submitted in person

This field is for validation purposes and should be left unchanged.

APPLICATION FOR

SHARED RECOVER HOUSING

Resident Information

MM slash DD slash YYYY
MM slash DD slash YYYY
Marital Status:
Gender:
Race:
Ethnicity:
Are you a Veteran?
Do you have an ID Card?
Do you have a EBT Card?

Who is your emergency Contact?

Income

Working
DOC Housing Voucher
Social Security Benefits
Drug Court Housing
HEN Program
Do you have a bank account?

Healthcare

Medicaid
State Health
Both
Other

Have you lived in Shared Housing?

Have you ever lost housing?(Required)

Incarceration or Arrests

Are any charges pending?(Required)

Work History

Are you looking for work?
Do you plan on school or training?

Tell Me about yourself

I acknowledge that I have read the house rules and agree to comply with the house rules.(Required)
House Rules
Your First and Last Name

Consent To Procedure and Access To Medical Records

Daffodil Place requires random urinalysis tests in the house and as a condition to entry to the house and remaining in the program. We do not require access to medical information, unless there is an emergency in the house, Or you are on medication prescribed by a physician or on a medically assisted treatment for addiction. Please initial where indicated.

1.1 Consent to Procedures: To arrange for and consent for urinalysis.

1.2 Access to Medical Records and Other Personal Information: The Client hereby allows physicians and psychiatrists who have treated the Client, and all other providers of health care, including hospitals, to release to the Daffodil Place information needed for medically assisted treatment as needed for supportive housing. With respect to Daffodil Place only, the Client hereby waives all privileges attached to the physician patient relationship and to any communication, verbal or written, arising out of such a relationship. Daffodil Place is authorized to request, receive and review any information, verbal or written, pertaining to the Client’s physical or mental health, including medical and hospital records, and to execute any releases, waivers or other documents that may be required in order to obtain such information, and to disclose such information to such persons, organizations and health care providers as Daffodil Place may designate.

Your First and Last Name

Photo Consent Form

I, the undersigned, of legal age, hereby irrevocably grant to DAFFODIL PLACE, LLC (www.daffodilplace.org) its subsidiaries, affiliates, agents, licensees, successors and assigns thereof (hereinafter referred to as “Company”), claiming under or through same, the following rights to use the materials and/or items described herein in any fashion, form, or media, whether currently in existence or hereinafter devised:

1. The right to photograph, record, videotape, store, and use the undersigned’s name, voice, appearance, likeness, signature and/or written testimony or statement along with any material furnished by me, in whole or in part, in any training, training materials and/or advertising materials produced, used or provided by Company, its subsidiaries, affiliates, agents, licensees, successors and assigns thereof, through means of mass, digital, and/or electronic media, including but not limited to printed, radio and television, promotional materials or events, and/or marketing plan, the Internet, and any other media and for all other types of advertising, publicity, promotion and other trade purposes for Company, its products and services;

2) The right to publish, text, exhibit, distribute and use the written or recorded testimonial or statement, or any parts thereof, my likeness and image, which shall appear as follows: first name and surname, general location of residence, and, where applicable, accompanied by photographs and/or recordings and/or signature, for commercial and/or non-commercial purposes, including but not limited to the advertising or solicitation of purchases, anywhere in the world where Company conducts business or intends to conduct business. I, the undersigned, hereby grant Company full ownership of and complete interest in any copyright I may have with regard to any written statement or other tangibly-fixed expression, which I have provided. I, the undersigned, hereby release and agree to indemnify and hold harmless Company, its subsidiaries, affiliates, officers, directors, agents, owners, employees, successors and assigns thereof, from any and all claims, actions, causes of action, damages, expenses, courts costs, attorney fees, liability damage or judgment suffered by the undersigned regarding the undersigned’s participation in or testimonial furnished by the undersigned to Company. I, the undersigned, hereby acknowledge that I have not been paid or otherwise compensated for the rights granted above. I further certify that all material, whether verbal, written or exhibited by me is not scripted or coached and represents my individual opinions and beliefs, and are true and correct to the best of my knowledge. I, the undersigned, hereby acknowledge that I have read this document and understand its contents. I further acknowledge that I have executed this document voluntarily.

Your First and Last Name