DO NOT FILL OUT, THIS IS A ONLY AN EXAMPLE OF THE APPLICATION.

THE LODGE PHILOSOPHY

We at THE LODGE believe that every recovering person has a responsibility to themselves and to the community not to become or remain a burden to society.

We believe that every person in recovery needs to give back what they have gotten, and our view is that no person shall sit in a bedroom and be sedentary.

THE LODGE insists that every tenant be employed within two weeks of residence or be engaged in meaningful and structured volunteer work. We are committed to assisting residents in finding employment and or directing them to those charities that need help. In addition, each resident of THE LODGE must have a sponsor and commit to attending a certain number of AA/NA/CA meetings per week.

Every tenant of THE LODGE must comply with this philosophy or find another place to reside. It is our sincere hope and desire that all who pass through our doors goes on to a better life, one filled with promise, self gratification and love. We cannot accomplish these goals by isolating; we need people and there are so many people that need us.

We hope that THE LODGE will be the beacon that guides you to a bright future. Staffed by professionals who walk the walk, we are 100% dedicated to providing the means for men
willing to do what it takes to change their lives and remain alcohol and drug free. Let us be a small part of your success.

Jim Tichy

The Lodge at Delray Beach

RESIDENCY STATEMENT

Recognizing my need for a safe recovery environment, I would like to apply for residency to The Lodge at Delray Beach.

I understand that I am a tenant and that Jim Tichy is my landlord at THE LODGE.

I understand that my residency at THE LODGE is complementary to my educational needs, an education on how to live a sober life. I am completely aware that THE LODGE is dedicated solely to the educational needs of the recovering person. I am further aware that my continued residence is dependent on needing such education and my willingness to help myself and others.

Should an accident involving personal injury to myself or loss or damage of personal property occur during my residence at THE LODGE, I agree for myself, my heirs or assigns, to hold Jim Tichy free and harmless from all liability in connection therewith.

Any personal property left upon my departure from the house which is not claimed within five (5) days by me or my authorized agent shall become the property of THE LODGE.

Anyone may be subject to dismissal for willful misconduct which is defined as conduct harmful to the reputation and best interest of THE LODGE. This dismissal will be in accordance with Section 117.06 of the City of Delray Beach Ordinance 30-09 Tenant/Occupant Eviction which requires either forty-eight (48) hours notice of eviction in writing or an alternate temporary dwelling unit for at least forty-eight (48) hours.

WEEKLY RENTAL AGREEMENT

Rental agreements are $215 per week. Rent not paid on or before the due date will be subject to a late charge of $2.00 per day.

Prior to occupancy, the following funds are required:

• First and last week rent
• $150 non-refundable administration fee

You have completed your commitment if:

• YOU HAVE REMAINED IN THE HOUSE FOR 185 DAYS (6 MONTHS).
• YOU HAVE DONE NO DAMAGE TO ANYONE’S PROPERTY.
• YOU HAVE GIVEN A FULL SEVEN DAYS NOTICE OF YOUR INTENT TO MOVE.
• YOU HAVE REMAINED DRUG & ALCOHOL FREE FOR 185 CONSECUTIVE DAYS (6 MONTHS).
• YOU HAVE RETURNED ALL KEYS.
• YOU HAVE NOT REMOVED ANY PROPERTY BELONGING TO THE LODGE. (SHEETS, TOWELS, SILVERWARE, ETC)

No amount will be returned or applied if you do not stay for 185 days (6 months), have used alcohol or drugs, or display behavior which is unacceptable. In addition, since rent is paid by the week, if you leave before the week is up, there will be no refunds made for unused days.

UNIT AGREEMENTS

1. Alcohol and drugs are not allowed on the property.

2. Please curb profane and indecent language.

3. Gambling in any form is not permitted on THE LODGE property.

4. Smoking is not allowed in the house.

5. Each person is responsible for their own cleanliness, the cleanliness of their room and the overall cleanliness of the house.

6. Visitors to THE LODGE must be approved and absolutely NO visitors are ever permitted in the bedrooms.

7. There will be no intimate behavior allowed with anyone within inside THE LODGE.

8. Each resident must notify the staff immediately if your prescribed medications change.

9. Unauthorized and unreported use if any mind-altering drugs (i.e. anti-depressants, etc.) will result in dismissal in accordance with Section 117.06 of the City of Delray Beach Ordinance 30-09 Tenant/Occupant Eviction which requires either forty-eight (48) hours notice of eviction in writing or an alternate temporary dwelling unit for at least forty-eight (48) hours.

10. No physical acting out – no yelling – no verbal threats!

11. Park cars in the driveway. Bicycles must be parked in the garage.

12. Do not repair your vehicles on THE LODGE property or on the neighborhood streets.

13. Curfew is at 11:00 PM every weeknight and 1:00 AM on weekends. This is strictly enforced. Failure to comply will result in your eviction and the house locks will be changed.

14. Each person is required to let the night manager know when you have come in for the evening.

15. After your first hundred (100) meetings / first hundred (100) days at THE LODGE you will be required to attend a minimum of five (5) meetings per week.

16. Residents must attend the weekly LODGE Community Meeting.

17. Each resident will be assigned a chore / chores. Failure to do so will result in that resident doing one (1) hour community service for THE LODGE.

18. Do not leave dirty dishes in the sink. It is the responsibility of each resident to wash their dishes right away.

19. Each resident is responsible for purchasing their own food. Use labels found in the kitchen to mark what is yours.

20. Borrowing without permission is stealing and will result in dismissal in accordance with Section 117.06 of the City of Delray Beach Ordinance 30-09 Tenant / Occupant Eviction which requires either forty-eight (48) hours notice of eviction in writing or an alternate temporary dwelling unit for at least forty-eight (48) hours.

PASS POLICY

POOL RULES

• The pool is open from dawn to dusk daily.
• No one shall use the pool unless they are employed, going to school or doing volunteer work.
• Visitors are only allowed at the pool with advanced permission.
• No loud music.
• No cigarette butts on the ground.
• No profane language or unacceptable behavior.
• No thong bathing suits.
• No food or glass containers.
• Violation of any of these rules will result in loss of pool privileges and / or eviction from THE LODGE.

DRUG TESTING

There will be intermittent random drug tests, for which each tenant will be financially responsible. Instant drug tests are $15.00 and lab tests are $50.00.

WHAT THE LODGE PROVIDES

• Bed linens, pillows and towels
• Pots and pans
• Dishes and silverware
• Bedroom furniture including bed, dresser, nightstand
• Living room furniture including couch, tables and television
• Dining room furniture including dining table and chairs
• Electricity, water and trash
• Pool facilities

WHAT THE LODGE DOES NOT PROVIDE

• Clothing
• Personal Grooming/Hygiene Supplies
• Individual television sets
• Telephone
• Laundry detergent/dryer sheets/etc
• Cleaning Supplies

APPLICATION FOR RESIDENCE

Name:__________________________________________ Date:______________

Address:________________________________________________________________

City:___________________________________ State:______ Zip Code:___________

Date of Birth:_____________________ Social Security #:_______________________

Driver’s License #:_______________________ Clean Date:___________________

Nearest Relative:_______________________________ Relationship:______________

Address:_________________________________________________________________

City:___________________________________ State:______ Zip Code:___________

Marital Status: ___ M ___ S ___ D ___ Sep Any Children? ___ Y ___ N

Names and ages of children:____________________________________________

Where do they live?___________________________________________________

Vehicle Make and Model:______________________________________________

Tag Number:______________________ Insurance Company:________________

Employer/ Supervisor Name:____________________________________________

Phone #:_____________________ Start Date:__________ Salary:_____________

Are you on disability? ___ Y ___ N

Community Control? ___ Y ___ N

House Arrest? ___ Y ___ N

Probation? ___ Y ___ N

Probation Officer/Phone #:_______________________________________________

TREATMENT HISTORY

List previous treatments:_____________________________________________________

__________________________________________________________________________

Medications:_______________________________________________________________

__________________________________________________________________________

Physician Name/Phone:______________________________________________________

Insurance Company:_________________________ Policy #:_______________________

MISC. HISTORY

Do you have an eating disorder? ________ Do you snore? __________

List your aftercare plans:______________________________________________________

____________________________________________________________________________

FINANCIAL INFO

Checking Account: ___ Y ___ N Savings Account: ___ Y ___ N

Monthly Income:_________________ Monthly Expenses:_______________________

How will you pay for THE LODGE:________________________________________________

THE LODGE accepts cash, checks and money orders. All payments are due in advance and weekly. Make checks payable to Jim Tichy.

THE LIFESTYLE

THE LODGE is based on the AA and NA way of life. I agree to live the AA and NA way of life as long as I am living at this residence.

HUNDRED (100) & HUNDRED (100)

I agree that for the first one hundred (100) days I will attend one hundred (100) meetings. A meeting is considered one of the following: AA, NA or CA. Any other group, therapy session or meeting with your sponsor does not take the place of a meeting unless you get prior approval.

I WILL:

• Attend at least five (5) AA, NA or CA meetings per week after I have completed my 100 and 100.
• Have a sponsor that I will talk with on a dally basis.
• Work the steps, starting with step one (1) and progressing to step twelve (12), in order.
• Pray daily, asking for help in the mornings and giving thanks in the evenings.
• Work the AA, NA or CA program!
• Not work my program or someone else’s program.
• Live at THE LODGE for 185 drug free days. (6 months)
• Follow all other agreements while at THE LODGE.