Step 1 of 2 50% Check-In and Check-OutSite*Recovery CapitalRequest ContactPlease provide the following information and we will get back to you shortly.HiddenSection BreakAre you:* Checking-In Checking-Out Have you registered as a Member of our Center?* Yes No Your Participant Short Code:* Your participant short code is your first initial, last initial, birth month, day and year in the following format: FL10211901 Where First Last's birth date is 10/21/1901.Do you want to register as a Member of our Center?* Yes No Name* First Last Phone*Please enter (000)-000-0000 if you do not have a phone numberEmail* If you don't have an email address, please input "no@email.com".What brings you into the Center today?* CRS Appointment Support Group Activity Visitor/Guest of a Member Please see a staff member to complete your registration.Name* First Last What Center Resources did you utilize today?* Computer/Laptop Library Socialization Game Activity Gym Equipment TV Support Group CRS Appointment Game* Board/Card/ Puzzle Skee Ball Darts Bubble Hockey Pool Basketball Foosball Xbox PlayStation Activity* Game Activity Arts/Crafts Personal Development Activity Education/Information Special Event/Party Recovery Pathway Activity Gym Equipment* Weight Machine Bike Treadmill Elliptical Support Group* All Recovery Meeting Family Support Group Which CRS did you have an appointment with?* Please briefly describe what you would like to discuss*HiddenRequest ContactPlease provide the following information and we will get back to you shortly.I am:* A current Member Interested in becoming a Member Please Enter Your Participant Short Code:* Your participant short code is your first initial, last initial, birth month, day and year in the following format: FL01311990 Where First Last's birth date is 01/31/1990.Name* First Last Please contact me via:* Phone Email Phone or Email Phone # for Contact*Email for Contact* Please briefly describe what you would like to us to contact you about*New MemberPlease create your new member record.Name* First Last Phone*Please enter (000)-000-0000 if you do not have a phone numberEmail If you don't have an email address, please input "no@email.com".Address* Street Address Address Line 2 City AlabamaAlaskaAmerican 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 County of Residence HiddenHow did you hear about us? Friend/Family Treatment Provider Probation officer Emergency Department Reason for Referral* Select All Housing Employment Education Connection to treatment Connection to recovery community Recovery support Probation Overdose Co-occurring Multiple treatment episodes Other Reason for Referral, if Other:* Demographic InformationDate of Birth* MM slash DD slash YYYY Race* Black or African American Asian Native Hawaiian/Pacific Islander Alaska Native White Native American Other Refused Race, if Other:* Ethnicity* Hispanic or Latino Not Hispanic or Latino Refused Gender* Male Female Transgender Non-binary Other Refused Gender, if Other:* Do you have health insurance?* No Yes Unknown What is your Health Insurance?* Private- Employer Private- Individual Medicare Medicaid Medicaid and Medicare Other Employment Status* Employed, Full Time Employed, Part Time Unemployed, Looking for work Unemployed, Not looking for work Disabled Volunteer Retired Other Refused Check all that apply to you:* IV Overdose Survivor Pregnant Veteran Co-Occurring(substance use disorder AND mental or physical health disorder) Medical Marijuana Pharmacotherapy(Buprenorphine, Naltrexone, Methadone) Probation/Parole(current) None Drug(s) formerly used: Alcohol Benzodiazepines Cannabis/Hashish Cocaine/Crack Methamphetamine Fentanyl Other Opiate/Opioid MDMA/Hallucinogens Inhalants Other Where do you live?* Housed Unhoused Shelter Recovery Residence Residential Treatment Institution Halfway House Other Refused Describe your living situation, if Other:* Please select which recovery path(s) you use.* Abstinence 12-Step Recovery Support groups Natural Recovery Peer Recovery support Medication-assisted Recovery Harm Reduction Alternative/Holistic Recovery Other Unknown Recovery Path, if Other:* Are you currently receiving treatment for Substance Use Disorder?* Yes No Where do you receive treatment for Substance Use Disorder?* Are you currently receiving treatment for Mental Health Disorder?* Yes No Where do you receive treatment for Mental Health Disorder?* What is your Recovery Date?* MM slash DD slash YYYY Do you currently have a Case Manager through Armstrong Indiana Clarion Drug and Alcohol Commission?* Yes No Who is your Case Manager?* Do you currently have a CRS through Armstrong Indiana Clarion Drug and Alcohol Commission?* Yes No Who is your CRS?* Are you interested in learning more about CM and/or CRS services through Armstrong Indiana Clarion Drug and Alcohol Commission?* Yes No If you have immediate needs, please call 724-545-1614.What does the term "Recovery" mean to you?*Describe you current state of Recovery:*Why do you want to become a Member of Recovery Capital?*How can Recovery Capital help your Recovery?* Recovery Guidance Recovery Education Health/Wellness Life Skills Socialization Recovery Support Groups Supportive Environment Activities None Are you interested in Telephone Recovery Support?* Yes No If you answer yes, you will be called 1 time per week based on the availability selected. You can change your calling preferences at a later date.Best Days to Call* Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Best Times to Call* Late Morning (9 to 12) Afternoon (12 to 3) Late Afternoon (3 to 5) Recovery Capital Member AgreementsEntry/Exit Members/guests are to enter and exit the building by way of front door only - unless incase of emergency or with staff approval.Entry/Exit* I have read and acceptComputer/Internet Use 1. Members/guests are not permitted to access offensive, sexually explicit, inappropriate, or otherwise illegal material via the Recovery Capital computers or internet service. 2. Members/guests are not permitted to install personal software on RecoveryCapital equipment. 3. Members/guests will sign out of all accounts/browsers when finished. 4. Members/guests will be respectful to the needs of others who require the use ofthe equipment. 5. Members/guests will provide proper care for equipment issued to them.Computer/Internet Use* I have read and acceptTelevision/Gaming Systems 1. Members/guests are not permitted to access offensive, sexually explicit, inappropriate, or otherwise illegal material via the Recovery Capital equipment or internet service. 2. Members/guests are not permitted to purchase, download, or install personal software on Recovery Capital equipment. 3. Members/guests are not permitted sign into personal accounts or subscriptions on the equipment. 4. Members/guests will be respectful to the needs of others who require the use of the equipment. 5. Members/guests will provide proper care for equipment and clean the equipment when finished.Television/Gaming Systems* I have read and acceptExercise Equipment 1. Members/guests are required to sign the Release & Waiver of Liability andIndemnity Agreement prior to using the equipment. 2. Members/guests are to participate in equipment orientation prior to using theequipment. 3. Members/guests are to wear appropriate attire when using the equipmentincluding footwear. 4. Members/guests will be respectful to others waiting to use the equipment.Continuous exercise on one machine should not exceed 30 minutes if others arewaiting. 5. Members/guests will provide proper care for equipment and clean the equipmentwhen finished.Exercise Equipment* I have read and acceptLibrary Books and Board/Card Games 1. Members/guests are not permitted to remove books and/or games from RecoveryCapital – they are to be used when visiting and will not be loaned out. 2. Members/guests will use notebooks for any workbook activity to preserve the integrity of the book. Library Books and Board/Card Games* I have read and acceptLaundry Machines 1. A washer and dryer are available for Member use only, not guests. 2. Members are prohibited from using the machines for excessively large, muddy, or greasy laundry. 3. Members are limited to no more than two (2) loads a day and no more than 4loads a week. 4. Members are to schedule laundry time on the sign up sheet. 5. Members are responsible for providing their own laundry soap/fabric softener. 6. Members are responsible to clean the machines and lint filters upon finishing.Laundry Machines* I have read and acceptConfidentiality 1. Confidentiality regulations and laws are put forth by the State and Federal government that all drug and alcohol agencies are mandated to follow. The laws can be found in the Federal Register – Title 42, Part 2 and ACT 63, Section 8 of“The Pennsylvania Drug and Alcohol Abuse Control Act,” issued in 1972. 2. Confidentiality laws are designed to protect the privacy of individuals. The laws insure that people can safely seek treatment without experiencing the negative consequences of public stigma, embarrassment, prejudice, and discrimination. The laws attempt to strike a balance between the need for privacy and anonymity on the part of the client and the need for information by agencies, officials, and other persons. 3. Any information relating to a client that is learned in connection with treatment is protected by confidentiality regulations. This includes identifying information, attendance record, status in treatment, and treatment records. All current and past employees, volunteers, and visitors must maintain strict confidentiality.Information is kept from everyone unless a specific provision is made in the regulations. 4. In the course of your visit to our agency, you may obtain client identifying information or see people you know. This is confidential information and should not be shared or discussed outside the agency. 5. Unauthorized disclosure of client information is a Federal criminal offense. For the first offense, a fine of $500 is levied and $5,000 for subsequent offenses.Confidentiality* I have read and acceptPhoto/Video 1. Members/guests are not permitted to take pictures or video via camera, cellphone, etc. without permission of the subject(s). 2. Members/guests will ensure that photos and video do not capture others in the background for the protection of their privacy. 3. Members/guests will be asked to delete unsolicited imaging from their device.Photo/Video* I have read and acceptSmoking/Vaping/Tobacco Use 1. Smoking/Vaping/Tobacco use are prohibited inside Recovery Capital. 2. Members/guests may only do so in designated areas outside of the building where butt receptacles need be used. 3. Smoking/Vaping is strictly prohibited in front of the building or nearby properties.Smoking/Vaping/Tobacco Use* I have read and acceptLoitering In order to protect the appearance of Recovery Capital and be good neighbors, loitering in front or at the side of the building is prohibited.Loitering* I have read and acceptHarassment Harassment on the basis of race, religion, color, national origin, ancestry, medical condition, disability, marital status, age, sex, sexual orientation, gender and gender identity is unacceptable and will not be tolerated.Harassment* I have read and acceptZero Tolerance Recovery Capital will not tolerate any of the following either on premises or in the vicinity: 1. Use of drugs or alcohol 2. Being under the influence of drugs or alcohol 3. Possession of alcohol, drugs or paraphernalia or other contraband 4. Intent to buy, sell, trade or seek drugs or alcohol 5. Possession of a weapon 6. Destruction of property or vandalism 7. Theft 8. Gambling 9. Loud and/or excessive expression of profanity or vulgarity 10. Any threatening behavior or verbiage 11. Fighting 12. Sexual Activity or associated behavior 13. Indecent ExposureZero Tolerance* I have read and acceptIncident Reporting For this purpose, "incident" refers to accidents, injuries, violations, concerning behavior and/or illegal activity. 1. Members/guests are responsible for reporting incidents involving another member/guest to a staff member or volunteer immediately. 2. Members/guests are responsible for reporting incidents involving Volunteers to a staff member immediately. 3. Members/guests are responsible for reporting incidents involving Staff to the Program Director to CRS Supervisor immediately.Incident Reporting* I have read and acceptSurveillance The interior and exterior of Recovery Capital are under 24/7 video recorded surveillance.Surveillance* I have read and acceptGuests 1. Members are permitted to bring guests as follows: 2. Guests are limited to designated guest days/times only. 3. Each member is limited to no more than two (2) guests at a time. 4. Guests must be at least eighteen (18) years of age. 5. Guests do not need to be in recovery but must be substance-free when visiting. 6. Guests must be accompanied by a Member. When the member leaves their guest(s) must leave. 7. Guests must sign in and out. 8. Guests will be required to sign a Visitor/Volunteer Confidentiality Agreement. 9. Guests must follow all policies. Members are responsible for their guests and for informing them of the policies. Members may incur consequences if their guest(s)violate any of the policies. 10. For the safety of Children, they are to always remain with a parent/legal guardian.Staff and Volunteers do not provide childcare.Guests* I have read and acceptMiscellaneous 1. Members/guests must sign in upon arrival and out upon departure. 2. Members/guests must clean up after themselves. 3. Members/guests must dress appropriately. Proper dress includes footwear and shirts. Clothing that is derogatory, insulting, suggestive, or bearing any relation to drug/alcohol promotion or use is not permitted. 4. No sex, sexual acts, or associated behavior. 5. Respect the premises, equipment, furniture and other people. 6. Please be mindful of Recovery Capital’s reputation by not disturbing or disrespecting adjoining properties when arriving, leaving, or utilizing outside space. 7. No sleeping 8. Medications are to be secured in your belongings and not on display. 9. Individuals appearing under the influence by way of sight, smell or hearing are not permitted on premisesMiscellaneous* I have read and acceptViolation of Rules Violation of any of these rules could lead to a suspension or termination of membership. Members have the right to appeal suspension or terminated membership. 1. A member may appeal suspension/terminated Memberships by submitting a written statement or by directly contacting the SCA Director or Deputy Director within seven (7) days. 2. The SCA Director or Deputy Director will discuss the case with the ProgramDirector or designee and render a decision as soon as possible but no later than fourteen (14) business days. 3. The individual will be informed of the decision in writing. 4. The SCA Director's or Deputy Director's decision is final. 5. The member cannot participate at Recovery Capital during the appeal process and appointments with CRS for RSS will be provided at an alternate location.Violation of Rules* I have read and acceptA copy of this form will be available to print upon submission. Code of Conduct may also be obtained by request at Recovery CapitalA copy of this form will be available to print upon submission.* I have read and acceptPlease enter your First and Last Name to acknowledge and submit the application* You will be required to sign the Confidentiality Agreement and Release & Waiver ofLiability and Indemnity Agreement upon issue of Membership ID.HiddenContact PreferencesHiddenI am interested in:* Recovery Coaching Telephonic Recovery Supports Both Telephonic and In-person Recovery Services HiddenBest Days to Call: Select All Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays HiddenBest Times to Call: Morning (Before 9) Late Morning (9 to 12) Afternoon (12 to 3) Late Afternoon (3 to 6) Evening (6 to 9) Late Night (After 9)