Collegiate Recovery Residency Application Home / Collegiate Recovery Residency Application "*" indicates required fields Fields marked with an * are requiredName* First Last Date of Birth* MM slash DD slash YYYY Email* Phone*Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name* Relationship* Contact Phone*Are you a person in recovery?* Yes No What does recovery look like for you?*Are you enrolled in or have applied to school?* Yes No 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).* Δ