request form
  1. SCROLL TO BOTTOM FOR APPLICATION FOR ADMISSIONS

    Welcome to
    Jacob’s Well Recovery Center
    for Women

    45 Buford Lane
    Poplarville, Ms 39470
    Fax (601)795-2803
    Admissions (601)909-5505
    Admissions (769)926-9942
    Admissions Information and
    Application for Residency Packet

    JACOB’S WELL RECOVERY CENTER FOR WOMEN
    45 BUFORD LANE
    POPLARVILLE, MISSISSIPPI 39470

    Jacob’s Well Recovery Center Introductory Letter

    Jacob's Well Recovery Center is a Christ centered addiction recovery center for women located near Poplarville, Mississippi. We are a privately owned, privately operated, nonprofit corporation organized under 501-c3 guidelines. Our ministry was established in June of 2005 by Founders and Ministry Directors Pastor Charlie Haynes and his wife Pam. Our recovery program is based on the healing power of our Lord and Savior Jesus Christ through whose Grace we believe and have been witness to the fact that women can be healed from ALL types of addiction once and for all and forever.

    Jacob's Well is a “resident” six month worship and work program where women are taught sound biblical principles of living by being required to sit under three hours of teachings, devotions and preaching every day six days a week and four hours on Sunday. These teachings, devotions and preaching are presented daily by a great staff of Pastors from many different Christ centered denominations who volunteer their time weekly to come and minister to the residents in the program. Jacob's Well is an interdenominational and inter-racial recovery program. In addition to a concentrated program of biblical teaching we also offer the residents a soundly structured daily schedule based on rules, policies and procedures that teach them responsible behavior and good work habits. Even during the work times the staff of the ministry encourages the residents to enter into and remain in fellowship with each other as they work together in such a way that they are daily building social skills that demonstrate the love and behavior of Christ one to the other.

    We consider Jacob's Well to be not only an INDIVIDUAL healing ministry but a FAMILY healing ministry as well. New residents are not allowed visitors or phone calls the first thirty days of residency to give them an opportunity to get firmly grounded in the program without distraction. However, after the initial thirty days of residency the families and significant people in the lives of the residents are not only INVITED but ENCOURAGED to come and take part in the healing process with their loved one. Our families are very important to us. Our visitations are generous and are centered around our worship services and teachings so that the families are led to come and worship with their loved one while they are healing. Our hope and desire is that by doing so the resident AND those significant to her will exit the program “equally yoked.” Jacob’s Well Recovery Center operates on only that money which God provides through the personal donations of local churches, civic organizations, individuals and the modest tuition that we ask of the residents who enter our program. Jacob's Well also works closely with the Miss. Dept. of Corrections, law enforcement and the judicial system to give women an alternative to incarceration when they run afoul of the law in their addictive behaviors.

    God has blessed us with a remarkable healing success in our program. An overwhelming number of the women who complete our program will remain free from their addiction and live productive lives. A very large percentage of the women who come through this program as well as family members will be led to Christ as their personal Lord and Savior or rededicate their lives to Christ and be baptized while they are in residency here. We are pleased and confident to say to all who will listen that God is doing a mighty work in the lives of otherwise broken and hopeless women and their families through the ministry of Jacob’s Well Recovery Center. May Christ receive all the glory for what He is doing in the lives of those He calls to this place? “By His stripes we are healed...”

    PLEASE NOTE:

    • Please read the Information Letter and Pre-assessment packet carefully Before you apply

    Where is Jacob’s Well located?

    • Travel Interstate 59 and get off at Exit #19. At the end of the ramp, turn WEST.
    • Travel 2.5 miles to the stop sign and turn RIGHT.
    • Travel .7 miles to Buford Lane. Turn LEFT on to Buford Lane
    • We are the second Building on your left on Buford Lane.

    How long is the program?

    • This is a Six Month residential program.

    What about medical care?

    • We are NOT a medical facility.
    • Narcotics, barbiturates, anti-depressants, psychotropic medications, or any other potentially addictive medications ARE NOT ALLOWED.
    • All APPROVED medications must be turned in to the staff upon admission.
    • Medical or Dental matters must be taken care of prior to enrollment.

    If a major medical condition occurs during the residents program, the resident will be asked to postpone her program and return after the medical condition has stabilized.

    • The resident is responsible for all costs of Off-Campus emergency medical care.

    What is the Cost? (*Fees are due prior to, or at the time of admission.)

    • The total program cost is $4,500.00 for 6 months which consists of the following:
    • *Registration fee $300.00 which includes:

    1. Application process
    2. Background check
    3. Initial and additional monthly drug screens
    4. Pregnancy test

    • *Monthly tuition fee of $700.00

    1. Room and board
    2. Three meals per day
    3. Laundry services
    4. All bedding
    5. Personal hygiene products

    What forms of payment are accepted?

    • We accept the following forms of payment: Cash, Check, Bank Draft, Money Order,

    Pay Pal/Credit Card
    Rules of admission:

    • Legal obligations of the resident must be handled by their legal representative.
    • Residents with non-legal obligations can be handled by the resident or a representative.
    • Make sure you are fully informed about our:

    1. Type of Program
    2. Policies: Medical and Legal

    • Financial obligations: MUST BE FULFILLED AS AGREED UPON in the application. Failure to meet the financial obligation may result in the termination of the resident’s care.
    • All court dates and legal obligations must be postponed until AFTER graduation. If, for someunforeseen reason the court date cannot be postponed, the resident may ONLY be transported by an approved representative.
    • Complete and fax the Application for Admission to:

    1. Admissions Fax: (601)795-2803
    2. Completed application and ALL required documentation must be received by the Admissions Office prior to admittance.

    • Send completed application AND cover sheet:

    1. Make sure to include your: Name, Address, and a Contact number on the cover sheet.
    2. You will be contacted upon our receipt of the Admissions Package for a face to faceinterview.
    Legal representative must attach the following documents:
    1. Legal status while in the program
    2. All orders pertaining to Jacob’s Well Recovery Center and the resident
    If approved:

    • You will be provided a date and time for admission. You must be checked into Jacob's Well Recovery Center within 24 hours of the “Face to Face” interview.

    What is the daily schedule?
    Monday through Friday:
    5:45AM—Wakeup Call
    6:15AM---Breakfast Fellowship
    6:45AM---Morning Devotion
    7:45AM---Morning Work Call
    11:00AM-Mid Day Devotion
    12:00PM- 1st Shift Lunch
    12:30PM- 2nd Shift Lunch
    4:00PM---Work Day Ends
    4:30PM-- Supper Fellowship/Free Time
    5:45PM---Evening Devotion
    8:30PM---Quiet Time
    10:00PM- Lights Out
    Saturday’s schedule is the same except:
    6:45AM—Wakeup Call
    9:00PM-Quiet Time
    10:30PM-Lights Out
    Sunday is scheduled as follows:
    7:45AM—Wakeup Call
    9:30AM--Leave to go to Church
    10:00AM—Church Service
    12:00PM---Fellowship Lunch
    2:00PM----Visitation Ends
    6:00PM---Testimony Service
    8:30PM—Quiet Time
    10:00PM—Lights Out
    ALL RESIDENTS ARE REQUIRED TO BE PRESENT AND SEATED 15 MINUTES PRIOR TO EACH SCHEDULED ACTIVITY.

    Will I be allowed visitors?
    Only the following people will be considered as candidates for visitation with a resident of Jacob’s Well Recovery Center.
    1) The resident’s IMMEDIATE family to include: Husband*, Children, Father, Mother, Brother, Sister, Grandparents, Grandchildren
    2) Pastor of the church in which the resident worshipped REGULARLY before entering the program.

    * In some cases a man who is considered significant in the resident’s life, but is NOT her spouse will be allowed to visit a resident. This will be decided at the discretion of the Ministry Director.

    Procedures: (Please comply with visitation rules.)

    • Please park and visit in the designated areas. Leave promptly at 2:00 pm.
    • Please leave all cell phones and purses in vehicle. (PHONES ARE NOT ALLOWED IN VISITATION AREA.)
    • Do not enter the residents living area.
    • Do not bring any prohibited items on campus.
    • Animals are NOT ALLOWED at visitation.
    • Only pre-approved visitors will be allowed at visitation.
    • We reserve the right to restrict visitation on an individual basis.
    • We reserve the right to search and or drug test any and all visitors.
    • A maximum of 2 ADULT visitors plus the children of the resident are allowed.

    What is the telephone policy?

    • Residents are scheduled one 15 minute phone call per day after the initial 30 days.
    • Residents cannot receive incoming calls.

    Is there a tobacco policy?
    Yes, tobacco products are allowed in the designated area only. You will be strongly encouraged to quit. Nicotine patches, gum, and other similar products are permitted.
    Can transportation arrangements me made?
    Prior to admission for those who travel a great distance, transportation arrangements can be made to have the resident picked up at the following locations:
    1. The Greyhound Bus Station in Hattiesburg, MS
    2. The Amtrak Train Station in Picayune, MS

    What items do I need to bring?
    NOTE: Due to limited space all clothing and shoes must fit into a designated dresser and a assigned closet space, not including linens. All other items must fit into an additional three foot container.

    • Personal Items:

    Although we are able to furnish all personal hygiene products the resident may bring the following items at their discretion: shampoo, soap, toothpaste, mouth wash (must be alcohol free), tampons, laundry detergent.

    • Classroom Supplies:

    Envelopes and Stamps
    Optional items to bring:

    • Snacks and drinks (we do provide a vending machine on campus).

    Dress code:
    Residents will dress in a manner appropriate to the weather conditions with modesty and respect for the goals and visions of Jacob’s Well Ministry. Included in this dress code, but not limited to these items would be:

    • No jewelry through pierced body parts (only pair of earrings in your ear)
    • No hats or head coverings allowed in devotions or worship services.
    • No bandanas, no do rags or hats turned backwards.
    • No sunglasses worn inside building or on top of your head.
    • No cut offs ( knee length shorts only)
    • No halter tops, exposed midriffs, low cut shirts or blouses.
    • Bras must be worn at all times.

    Free-time dress code:

    • Residents must remain fully dressed at all times when they are present in the common areas of the ministry.
    • Residents must be fully dressed for all teachings, preaching’s and devotions (No pajamas!!)

    Bedtime dress code:

    • At bedtime, residents may wear Pajamas, Nightgowns, Night shirts, Sweats or T-shirts (No Nudity).
    • Any resident leaving her room must be fully dressed (including bra).

    What items are prohibited?

    • Drugs, alcohol, non-approved medication

    All over the counter medication. Cigarettes must be turned into staff with an un-broken seal

    • Anything containing alcohol: mouthwash, cologne, hairspray, etc
    • Pocket knife or any item that can be considered a weapon
    • Any electronic devices, including but not limited to: Ipod/MP3 players, camera, cell phone, computer, radio
    • Musical instruments, magazines, hot plate, toaster, etc…
    • Jewelry (no facial or body jewelry allowed). A single pair of earrings only worn in the bottom hole will be allowed.
    • Personal vehicles
    • No references to alcohol, gambling, profanity, or war stories

    REQUEST FOR ADMISSION
    Please Print and Answer All the Questions

    Admission Staff Use Only

    Received:___________ Entered:_________ Approved:_________ Admission Date:_________

  2.  
  1. A. Resident’s personal data:

  2. Name(*)
    Please write your name.
  3. SSN(*)
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  4. Permanent Address:(*)
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  5. County/Parish:(*)
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  6. City:(*)
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  7. State:(*)
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  8. Zip:(*)
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  9. Age:(*)
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  10. Birth Date:(*)
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  11. Home Phone:(*)
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  12. Cell Phone:(*)
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  13. Fax Number:(*)
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  14. Please check all that apply:

  15. Marital Status(*)
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  16. Race(*)
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  17. Religious Background:(*)
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  18. Attended Jacob’s Well:
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  19. When Attended
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  20. Graduated:(*)
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  21. Custody of Children:(*)
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  22. B. Emergency contact 1:

  23. Name:(*)
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  24. Relationship:(*)
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  25. Address:(*)
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  26. County/Parish:(*)
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  27. City:(*)
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  28. State:(*)
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  29. Zip:(*)
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  30. Home Phone:(*)
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  31. Cell Phone:(*)
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  32. C. Emergency contact 2:

  33. Name:(*)
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  34. Relationship:(*)
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  35. Address:(*)
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  36. County/Parish:(*)
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  37. City:(*)
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  38. State:(*)
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  39. Zip:(*)
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  40. Home Phone:(*)
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  41. Cell Phone:(*)
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  42.  
  1. D. Required information: (Must be completed in full)

  2. Level of Education:(*)
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  3. GED:(*)
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  4. Special Skills/Trades:
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  5. Driver License #(*)
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  6. State:(*)
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  7. Valid(*)
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  8. Any DUI’s
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  9. Any Physical Handicaps:
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  10. Work history:

  11. Employed:(*)
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    if yes, please fill up the below information.
  12. Last Date of Employment:
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  13. Employer:(*)
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  14. Occupation:(*)
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  15. Employer Address:(*)
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  16. Phone:(*)
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  17. E. Medical information

  18. Health History:(*)
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  19. Have you ever been diagnosed with a psychiatric disorder(s)?(*)
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  20. Diagnosis
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  21. Medications
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  22. When
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  23. Length of treatment
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  24. Have you ever been in treatment for substance abuse?(*)
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    if yes please fill up the below information.
  25. Date of treatment:
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  26. Treatment facility:
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  27. Period of effectiveness:
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  28. Use of Tobacco:

  29. Do you use tobacco products?(*)
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    If yes, please fill up the below information.
  30. Packs
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  31. You will be strongly encouraged to quit. Nicotine patches and gum are permitted.

  32. Addiction History: (Check all that apply. Please circle primary reason for admission.)(*)
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  33. Are you presently taking illicit drug(s):
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  34. Please list non-prescribed drugs you are presently taking:(*)
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  35. Are you prescribed any medication(s):
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  36. Please list ANY prescribed medication(s):(*)
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  37. Jacob’s Well Medication & Medical Policy

    • We are NOT a medical facility.
    • Narcotics, barbiturates, anti-depressants, psychotropic, psychoactive medications or ANY OTHER potentially addictive medications ARE NOT ALLOWED.
    • Medical or Dental matters must be completed PRIOR TO ENROLLMENT.
    • In the Case of a Medical Emergency a resident will transported to the emergency room BY AMBULANCE at the resident’s expense.
    • The resident is responsible for ALL costs of off-campus medical care. The resident is also responsible for ALL costs of ANY medications.
  38.  
  1. F. Legal information (Prior to admission)

  2. A background check will be done on the applicant. Please attach a copy of the following:
    1. Drivers license (or picture identification)
    2. Social Security Card

    • All court dates must be postponed while in the program.
    • Applicants entering the program without notifying the court/probation office (PO) IN ADVANCE may be disqualified and required to leave the program.
    • Court or PO phone calls or progress reports will be provided upon request.
    • The Court or PO may contact the resident’s counselor to check the resident’s status.
    • The Court/PO WILL BE NOTIFIED in the case of dismissal, leaving the program, or not fulfilling the financial obligations to Jacob’s Well Recovery Center.
  3. Court dates pending:
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    If yes, please fill up the below information.
  4. When:
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  5. Where
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  6. Are you currently on probation?
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    If yes, please fill up the below information.
  7. Probation officer:
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  8. County/Parish:
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  9. Phone:
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  10. Are you currently under court order?
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    (Court Order must be attached to the application)
  11. Did you notify the Court/Probation Office (PO) about entering Jacob’s Well?
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  12. Have you ever plead guilty to or been convicted of a crime?(*)
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  13. Have you ever been in prison?(*)
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    If yes, please fill up the below information.
  14. How many times?
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  15. Last date:
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  16. G. Fees & Payments

  17. Residents Name:(*)
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  18. SSN(*)
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  19. Responsible Party Name:(*)
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  20. Phone:(*)
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  21. PAYMENT IS DUE AT OR BEFORE TIME OF ADMISSION

    Please check one of the following Type of Payment:

  22. Type of Payment:(*)
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  23. The following statement MUST be signed before the application will be considered.

    Waiver of Liability and Acceptance of Responsibility: “I will not hold Jacob’s Well Ministries or its volunteers responsible for accidents or injuries that may occur during my enrollment in the program. I will be responsible for the cost of all medical care. I understand that Jacob’s Well is NOT a medical facility or psychiatric facility. I authorize Jacob’s Well Ministries to share my personal medical information with medical personnel in case of medical emergencies while I am enrolled in the program. I agree to be responsible for the entire program fee of $4500.00. Furthermore, I understand that Jacob’s Well Ministries is not responsible for any resident’s lost, stolen, or abandoned articles.”

    Signature(s):__________________ (Responsible Party)

    _________________ (Resident)

    Refund Policy
    Please Note the following policies:
    • In the case of dismissal from Jacob’s Well, for consistent violations of the policies and procedures, no refund will be given.
    • The registration fee is NON-REFUNDABLE. In addition to these fees, any cost of transportation or other non-regular costs incurred by Jacob’s Well Ministries due to the residents stay or dismissal will be added together and subtracted from the payments received.
  24.  
  1. H. Visitor’s list

  2. Residents name:(*)
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  3. Please make note of the following policies:

    • Visitation is for immediate family only.
    • Visitation is each Sunday from 10:00 am to 2:00 pm.
    • All visitors must be approved prior to visitation by Jacob’s Well Directors/Staff.
    • Jacob’s Well Reserves the Right to search any and all vehicles, personal properties, and drug test any individual on the premises.
    • Jacob’s Well Reserves the Right to refuse admission to the facilities to any one for any reason.
  4. THIS LIST MUST BE COMPLETED FULLY PRIOR TO ADMISSION. ALL INFORMATION IS REQUIRED
  5. Visitor's Details:(*)
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  6. I understand that I am responsible for the actions of my visitors. If they do not comply by
    the visitation rules, including un-authorized visits I may be subject to the loss of visitation
    privileges. I further understand necessary legal action will be taken in suitable situations.
  7. I. Resident’s acknowledgement
  8. I, hereby acknowledge the following to be true:

    • That I have read and completed this entire Request for Admission form and/or have had it explained to me and my questions about it answered to my satisfaction.
    • That I understand that Jacob’s Well Recovery Center is not required to admit me to their program.
    • That I understand that if I am admitted into Jacob’s Well Recovery Centers Program, that I understand Jacob’s Well has the right to dismiss me from their Program at their sole discretion for consistent failure to follow the rules policies and procedures, determined solely by and in the sole discretion of Jacob’s Well Recovery Center: and
    • That if I am admitted to the program I will abide by all of the Rules, Policies, and Procedures of Jacob’s Well Recovery Center and will respect the other residents and staff at Jacob’s Well Recovery Center.
  9. Resident’s Printed Name:(*)
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  10. Residents Signature:(*)
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  11. Date:(*)
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  12. Witness’ Printed Name:(*)
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  13. Witness’ Signature:(*)
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  14. Application checklist:
    Please verify the following before turning in the application:

    • The application is completely filled out. Incomplete applications will not be considered.
    • Legal information has been completed.
    • Courts and Probation Officers have been contacted and court dates postponed.
    • Responsible Party and/or Resident has signed section G. (Financial Information)
    • Visitation information has been fully completed.
    • Resident and Witness have signed Section I. Resident’s acknowledgement, in the presence of a Director and/or Member of Staff.