If you want to pay by Zelle, Venmo or Check instead of paying by Credit or Debit Card or Paypal, copy the following link and paste it into your browser. https://rhs.recoveryhousesoftware.com/web_report.php?formId=60&id=rhsoftware_RHM3 ***Please note that we cannot complete your application without payment for your Background Check.***

Written Disclosure, Consent, and Authorization I understand that the Employer/Center, Ruth House Ministries Inc, (“Employer”) will utilize the services of Horizon Background Screening, 12460 Crabapple Rd, Suite 202-271, Alpharetta, GA 30004, 404-556-1349 (the “Agency), to obtain a consumer report and/or investigative consumer report (“Report”) as part of its review of my application for employment. I also understand that if hired, to the extent permitted by law, the Employer may obtain further Reports throughout my employment for an employment purpose from a consumer reporting agency. I understand the Agency’s investigation may include obtaining information regarding my credit background, bankruptcies, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support, accounts placed for collection, character, general reputation, personal characteristics and standard of living, driving record and criminal record, subject to any limitations imposed by applicable federal and state law. I understand such information may be obtained through direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons who may have such knowledge. If an investigative consumer report is being requested, I understand such information may be obtained through any means, including but not limited to personal interviews with my acquaintances and/or associates or with others whom I am acquainted. I acknowledge receipt of the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, any related state summary of rights (collectively “Summaries of Rights”). This consent will not affect my ability to question or dispute the accuracy of any information contained in a Report. I understand if the Employer makes a conditional decision to disqualify me based all or in part on my Report, I will be provided with a copy of the Report and another copy of the Summaries of Rights, and if I disagree with the accuracy of the purported disqualifying information in the Report, I must notify the Employer within five business days of my receipt of the Report that I am challenging the accuracy of such information with the Employer. I hereby consent to this investigation and authorize the Company to procure a consumer report and investigative consumer report on my background as stated above from a consumer reporting agency and/or investigative consumer reporting agency.

ARE NOT ALLOWED IN THIS MINISTRY, AS WELL AS ANY MEDICATION DEEMED UNACCEPTABLE BY LEADERSHIP.

I understand that I am under the care and direction of RHM while I am in this program and reside at this facility. I agree and will comply with all rules and regulations listed in the RHM Manual.

1. Each resident is expected to practice proper hygiene by taking a bath, brushing teeth, and wearing clean and acceptable clothing. Appropriate and acceptable clothing is considered to be: Jeans, Khaki pants and Shirts that do not have any propaganda or logos for any alcoholic or drug related items on them. You can wear t-shirts that have company logos as long as they are not vulgar and or drug or alcohol related. Shorts must be no shorter than 3 inches above the center of the knee. Shirts and shoes must be worn in all common areas and outside. Staff will be the interpreter of the dress code rules. 2. SMOKING IS NOT ALLOWED. No nicotine in any form, no vaping, chewing, dipping, etc. ON OR OFF SITE. 3. Do not remove food, utensils, or any kitchen products from the dining area. 4. Any food in bedrooms must be in a sealed container. 5. Medications of any kind may only be used if approved by the staff. All medication is to be given to the staff to be locked up and given to the client for self-administration at the correct times. Medications must be on the approved list. NO NARCOTICS ALLOWED. 6. Turn off all electrical units when not in rooms. 7. No one is allowed in any other resident’s room. 8. Beds must be made and rooms must be straightened every day before quiet time. 9. Do not play radios loudly. If it can be heard outside of your room, it is considered too loud. 10. Guests are not to be invited outside of visitation hours without proper authorization. 11. No TVs are allowed in bedrooms TV privileges are just that, a privilege not a right. Your privileges can be taken away if used improperly. Videos that are not approved by leadership will be considered disobedience. If disobedience is found to be consistent, then TV privileges can be removed from the house. 12. Music or literature that is uplifting or instructive only, is allowed in the ministry. 13. Do not leave ministry grounds without permission. 14. No construction, rearrangement, or building without proper authorization. 15. Weekly and weekend schedules will be followed. 16. New or fledgling romantic relationships severely complicate recovery. First, work on you, then on your relationship with others. Relationships are generally defined as married. Any other will be assessed on a case by case basis. 17. Insubordination and/or disrespect toward staff and leaders will not be tolerated. 18. No person will have over twenty dollars in cash on their person or in their room. 19. NO DRUGS OR ALCOHOL ON PREMISES AT ANY TIME. 20. ABSOLUTELY NO VIOLENCE. Aggressive physical contact, verbal threats, and or combative stance are considered to be a form of violence. You can be dismissed from this facility because of a verbal and/or combative threat to staff, leadership, or other residents of the house. Abuse in any form is grounds for dismissal. 21. Residents who are released from the Ruth House voluntarily or for cause are expected to arrange for transportation for them and their belongings immediately. If the resident’s arrangements do not meet the expectations of Ruth House Staff, the resident will be transported by whatever means Ruth House chooses to Jasper, Calhoun, or Cartersville at the choice of the resident. Appropriate Court Officers will be notified by Ruth House. We want you to feel as much at home here as possible. We are not an establishment or facility for you to be warehoused. We are a home, living for God and for one another. While you are here you are encouraged to receive and to give the love of Christ, which is His greatest commandment and our great commission on Earth. We have many rules that we must follow in order to be successful in recovery. Our desire is to bring you to a place where you can learn to love God above all things and to learn to rely on Him fully for all things. Once that is accomplished, you will not only be delivered from your addictions, but will become a blessing to God, Church and Family. You must read and sign and initial all documents indicating that you understand and agree to all of these rules and guidelines before entering this program. Do not ask to change the rules or to get special privileges. This is looked upon as being disobedient. Your past obedience will be considered when the opportunity for special privileges arises. I understand and agree with all the rules and guidelines set forth in these documents. I agree by my signature to follow and comply with all rules and regulations set forth and acknowledge that failure to follow these rules and regulations may be reason for disciplinary actions or dismissal from this Ministry.

I hereby assume any risks that may be incident to my stay here and do hereby for my heirs, executors, administrator, myself or any personal representative, release and relinquish forever any and all claims of any nature whatsoever that might arise out of my stay at the Ruth House. I assume responsibility for any medical treatment that may occur during my stay at the Ruth House. I do hereby promise and agree that I will cooperate with the rules of Ruth House Ministries Inc, to the best of my ability and that I will carry out the work assigned to me in maintaining the Ruth House as my physical condition permits and to the best of my ability. I have read and or have had read to me all the foregoing questions and/or statements and have made the answers thereto contained in this application and am fully aware of the meaning of the same and I willingly and personally sign this application and contract fully knowing what I am doing. I understand and agree that random drug and alcohol tests are a part of this program and I will waive any rights that I may have and fully acknowledge and agree to a drug and/or alcohol test any time that I am asked to give one. If I refuse or fail to take a test when asked, I understand that I will be asked to leave this program. NOTE: NO PERSON OTHER THAN THE APPLICANT IS AUTHORIZED TO SIGN THIS APPLICATION/CONTRACT SECTION.

The recovery of each woman is dependent upon many things. It is determined by their willingness to change, to allow God into their lives, and it is also determined by family/sponsor involvement. There must be family/sponsor involvement and agreement with the ministry rules and regulations for this ministry to be effective. The family/sponsor has to be willing to adhere to all the rules and regulations put in place by this ministry during the times that the resident participates. This includes but is not limited to the week-ends home, special holiday times, transportation to and from doctor’s appointments and/or legal appointments, etc. Every family member and/or sponsor must sign this agreement in order to be allowed to visit her family member that is in the Ruth House facility. The purpose for this agreement is to make all parties aware of the rules and regulations set forth by this ministry for each resident involved. By signing this agreement the family/sponsor agrees to hold your loved one accountable for her actions during the time that she is with you. This agreement is to help you, the family/sponsor, have a better understanding of this ministry and what we are trying to achieve. It is our belief and hope that by sharing with you the rules and regulations and by entering into an agreement with you, equipping you with the tools to hold your loved one accountable, that you will be able to concentrate more on the healing and restoration process that you and your loved one(s) deserves. I agree to follow all the rules, regulations and guidelines set forth by Ruth House Ministries Inc. I agree that if my loved one(s) fails to adhere to any of these rules and guidelines that I will contact staff and let them know immediately. I agree to come to any meeting that is called by the Ruth House and will be willing and able to discuss all issues that this ministry feels affects my loved one(s) or my family. I agree to remain open and honest in all situations, stating the facts, as I know them and listening to all sides of the situation. I promise to uphold this ministry at all times and defer back to staff with any decisions that are made without their knowledge. I understand that this agreement is made in an effort to keep all parties involved transparent before one another, to keep open the line of communication between family, sponsor, resident and ministry staff, and to keep the focus of each resident on God and His will in our lives and not on each other. I agree that I will uphold the decisions made by Ruth House Ministries Inc in the area of discipline issued and given to my loved one(s). If we do not agree on the discipline set forth, I understand that I have the right to ask for a meeting with the Ruth House to discuss the situation. I also understand that if I discuss the discipline given in a negative or contradictory way with anyone other than the Ruth House staff, that I will be considered to be sowing seeds of discord. I understand that if I am sowing seeds of discord my loved one(s) may be in jeopardy of losing her place in this facility. I understand that this ministry will not tolerate discord brought about by verbal or physical actions taken by the resident, and or her family member or sponsor. I am making the commitment by my signature that I will not sow seeds of discord. I understand that every opportunity will be given to me to state my concerns and opinions.

The following is the maximum number allowed for each item. 12 outfits (which includes church and work clothes combined) 6 pairs of shoes 10 pair socks and under-clothes 2 jackets 2 Pillow Personal items (pictures, journals, etc, at staff discretion) Alarm Clock Razors Soap Shampoo and Conditioner Deodorant Toothpaste & Toothbrush Bible Paper & Pen Stamps & Envelopes Christian music, magazines and books RESIDENTS ARE NOT TO SHARE OR GIVE THEIR PERSONAL ITEMS TO OTHERS FOR ANY REASON. IF AN EMERGENCY ARISES, RUTH HOUSE WILL MEET THOSE NEEDS. Any personal property left upon a resident’s departure from this facility and not claimed within three (3) days by the resident or their authorized representative shall become the property of the ministry to dispose of for the best interest of the ministry.

The 1st phase of the Ministry is the most intensive and is approximately the first THREE (3) months as a resident. Most of the women that enter the program are in need of someone to sponsor them for that time. In the 2nd phase of the Ministry, the women are required to obtain employment as part of recovery. They can then pay the monthly payment as selected below until paid in full before they graduate. Transition is available after graduation for $500 a month. Certain individual costs Ruth House incurs will be added to tuition obligations. Examples are transportation not deemed a Ruth House function, pre-graduation personal items; court/probation costs; and medical prescriptions (not to exceed $50 total). Please sign to agree to the below payment terms. $500 intake fee $100 medical exam fee, with Sponsor or Client paying $900 per month for the first FOUR (4) months. Then the resident will pay $900 per month from employment for the final EIGHT (8) months for a total program cost of $11,400. The client cannot graduate without paying all costs in full, and therefore must remain in the program at full price until their fees are paid. If for some reason the payments stop, we expect the resident to secure another sponsor or obtain funds to continue to pay the program cost. If no arrangements can be made she must seek to find herself another program she can afford. Ruth House will try to help her find something else but we will not take on that responsibility.

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I authorize Ruth House Ministries, Inc. to disclose to, State, Federal, or local probation and parole officers or court officials and verified family members the following information: Program attendance and participation information. The purpose of the disclosure authorized in this consent is to document your progress in program attendance and participation. I understand that my alcohol and/or drug treatment records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. My signature below permits the Ruth House to disclose this information as needed. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows: 90 days after completion or exiting the Ruth House Program. I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I have been provided a copy of this form.

Ruth House Ministries Inc is not responsible for the physical and or mental condition of any residents that enter this facility. We do not have the medical facilities to attend to any physical and or mental health issues of the residents. We will supervise self-administration of client medications that are legally prescribed to a resident if those medications are taken orally and/or are not to be considered dangerous or unacceptable to this ministry. A person may be refused admission into this facility or discharged if her medical condition is considered beyond our abilities to meet her needs. A resident may also be terminated if it has been determined that she has falsified documents or she is suspected of abusing her need for medications that are deemed dangerous or unacceptable to this facility. Any resident that has or develops medical needs or has needs for medications will be responsible for purchasing or making arrangements to receive those medications by methods other than this facility.

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Intake Form Process and Completion Checklist: 1) Phone interview completed date ______ 2) 3-5 page letter of request to enter the facility. 3) Personal interview with Pastoral Staff at our facility. Staff Member_________________________ Date ______ 4) This intake form is completed and the entrance fee paid.

$ 35.00 Background Check for Sexual or Violent Battery Charges $ 900.00 Basic Recovery Program (1 monthly communication with Supervising Officer). Includes bed, food, Recovery Program supplies, counseling, transportation to group events. Does NOT include specialty foods, individual transportation to appointments, etc. ALL FEES ARE NONREFUNDABLE. Payments must be RECEIVED by the LAST BUSINESS day of the month for the next month’s Program. (October payment is due on the last business day of September.) NON-REFUNDABLE $ 500.00 Intake Fee. NON-REFUNDABLE. $ 100.00 Medical Exam and Testing Fee $ 10.00 Per each TYPE (EtG, 12 Panel, Nicotine, Synthetic, etc.) of Drug Test (if more than once per month is required). If Staff suspects drug use and the client is clean, RH will pay for the tests. Otherwise, the client will pay for any required additional tests. $ 40.00 Per hair follicle drug test if required more than three times per year. Calculation: Transportation charges - $0.585 per mile with standard gas prices below $4.00 per gallon. As fuel prices increase, so will the per mile price for transportation. Replacement Value: Value of any item broken by client I understand and agree to the above-referenced fee schedule.