Collegiate Recovery Residency Application

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"*" indicates required fields

Fields marked with an * are required

Name*

Date of Birth*

Email*

Phone*

Address*

Emergency Contact Name*

Relationship*

Contact Phone*

Are you a person in recovery?*

Yes

What does recovery look like for you?*

Are you enrolled in or have applied to school?*

Yes

Where?*

Collegiate Recovery Contact Name*

Collegiate Recovery Phone Number*

Please describe your income or resources available to pay your weekly fees.*

Vehicle Make and Model

Vehicle Tag Number

Insurance Policy Holder

Policy Number

I affirm that I have answered this application truthfully (type full name).*