Assisting in the Transition of Non-Violent, Male, Ex-Offenders from Prison 215 Clayton Street

Renascence, Inc.

Assisting in the transition of non-violent, male, ex-offenders from prison 215 Clayton Street

to a successful reintegration into the local community. Montgomery, Alabama 36104

Phone (334)

Date:______

Dear Sir:

Thank you for your interest in the Renascence Re-entry Program. Please read the following information carefully. We want to avoid any implication of acceptance, but wish to gather more information prior to submission of candidates to our selection committee. Enclosed you will find: an Authorization to Release Confidential Information, Renascence Resident Application, a Residency Contract (to be completed and signed by you) and a Verification of Non-violent/Non-Sexual Related Status form (to be completed and signed by Department of Corrections staff and return to us as soon as possible). Our major concern is to be certain there are no violent or sex offenses because of our covenant with the City of Montgomery to exclude violent or sex offenders. Thoroughness, integrity and honesty are the principles that our program is based upon, so please be clear and honest about your criminal history and strengths you would bring to the program. Incomplete applications will not be considered. Applicants accepted into the program are expected to remain in the program a minimum of six months.

We would also like to secure an Adult Psychosocial Assessment to be completed by the prison’s psychologist or other Master’s level staff and mailed to us. This is not mandatory for possible acceptance into the Renascence Program, but it helps us devise an individualized re-entry plan.

We are looking forward to hearing from you soon and hope to be of assistance during your successful transition back into the community.

Dana DunklinDereck Wise

Executive DirectorAdministrative Aide

Renascence, IncRenascence, Inc.

“ People might not get all they work for in this world, but they must certainly work for all they get.” . . . Fredrick Douglass

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RENASCENCE, INC.

PROGRAM APPLICATION

Renascence, Inc. Re-Admit____ New Admit____

215 Clayton Street Initial Admit Date ____/___/___

Montgomery, AL 36104 Current Admit Date ___/___/___

Disclosure of information contained in this Admission/Assessment concerning a client in Renascence, Inc. Programs is made to this Program with the consent of such client. The information may be used in the following capacity:

Internal Program communication.
Crimes, or threats of crimes, committed on premises or against staff.
Medical emergencies.
Reporting to appropriate authorities incidents of suspected child abuse/neglect.
Research, client will be notified if research is being conducted, and other safeguards must be observed.
Audit and/or evaluation of Program activities.
Federal, State, or local court orders, after following specific procedures.

I, the undersigned, do understand and accept the above.

______

Client’s Signature and DateWitness’ Signature and Date

______

A. Descriptive:

Name ______Name at Birth ______

Preferred Name______Age______Date of Birth ____/___/___

Current Address Street______City______State______Zip______

SS#____-____-_____ Race______AIS# ______

Emergency Contact Person ______Relationship______

Address ______City ______State ______Zip ______

Phone______Additional Phone ______

Mother’s Name______Describe your relationship______

Father’s Name______Describe your relationship______

List brothers/sisters and their age______

Children Under the Age of 18 ______(#)

Name Age Parental Rights DYS Involved Living Arrangements

Terminated (Y N In Process)

If DYS Involvement, Case Worker ______Phone ______

Belief in Higher Power_____ please describe______

Church Preference______

B. Employment and Housing:

Do you currently have the offer of a job_____ If yes, give name and address of employer ______

Last job salary $______per______Hours worked per week_____

More than one employer in the last year (outside of prison) worked_____ If yes, how many_____

Reason for leaving job______Are you currently able to work_____

Does someone contribute to your financial support in any way_____ If yes, explain______

______

Have you earned any income within the past year ______If yes, how much ______

In addition to applying to Renascence, Inc. what efforts have you made during your current incarceration to obtain housing or a home plan ______

Why, without supportive housing provided by Renascence, Inc. would you be living on the street or in an emergency shelter ______

D. Family/Social Background:

Marital status: Never married ____ Married _ ___Separated ____Divorced ____Widowed

How long has this been your marital status? _____

Is your family/significant other supportive of you entering this Program? _____

Does any member of your immediate family have, or has had, a problem with drugs/alcohol or the criminal justice system _____ If yes, please explain______

E. Medical Background:

Do you have any concerns about your health____ If yes, please explain______

Any chronic medical problems: (i.e. Asthma, Diabetes, Hepatitis, Seizures) ____Yes ____No

If Yes, please describe______

Allergies______Current Medications______Disabilities______

Do you have a doctor____ If yes, please specify whom______

Do you have any physical problems that would cause you difficulty in this program____ If yes, please explain______

Have you had any treatment for mental illness____ If yes, please explain when, where, and for what type illness______

Any past suicide attempts ___Yes ___ No Are you currently having thoughts of suicide ___Yes ___ No

If Yes, Describe______

If Yes, Are You Getting Treatment ___ Yes ___No____ Medication ____ Therapy ____ Both

C. Education

Highest grade completed in school_____ Earned GED_____ College or technical school______

______How did you get along with your teachers______

Favorite subject______Special talents/abilities______

What program(s) did you attempt or complete (GED, trade school, substance abuse treatment, Long Distance Dads, college correspondence credits, etc.) while serving your current prison sentence?

PLEASE INCLUDE PLACE AND DATE(S).

Program Name

Location

Dates Attended

Completed

YES/NO

F. Substance Abuse Background:

Age Resident Began Using: ____

SubstanceAge First Use FrequencyRoutes How Long UsedLast Date of Use

______

______
______

______

Longest Time Drug And Alcohol Free: ______(# of days, mos. Or years)

D. Legal Background:

Current place of incarceration______

Was this referral to Renascence, Inc. prompted/suggested by the criminal justice system (i.e. Judge, counselor, parole/probation officer) ______If yes, please specify ______

Have you ever returned to prison because of parole/ probation violation If yes please explain

Arrest History:

Offense

Date of Arrest

Convicted

(Yes/No) /

Date of Conviction

Length of Sentence

Amount time served

Arrest related to Substance Abuse

(Yes/No)

Please Explain

For what crime(s) you are currently serving a prison sentence

Date you were arrested ______Date you were convicted ______Date you were sentenced ______

Sentencing court______Name of judge______Probation Officer______

Length of current sentence: ______

Number of years you have already served for current conviction(s)______

Current parole consideration date for possible release under conditions of parole ______

Expiration Of Sentence (EOS) date: ______

Have you ever returned to prison for parole violation _____No _____Yes, if yes please explain in detail (including date of violation):

Any court appearances currently pending, probation/parole, special conditions, community service, fines, restitution, court cost, attorney’s fees, child support, victims restitution_____ If yes, please describe______

Additional Comments:

CERTIFICATION STATEMENT

I certify that all statements on or attached to this application are true and correct to the best of my knowledge. I know that any false statements may cause me to be denied the chance for possible acceptance into the Renascence Re-entry Community. I further authorize the release of all relevant prior employment, military service, academic/school and criminal records checks. If accepted into the Renascence Program I agree to abide by all Renascence Re-entry Community Rules.

Applicant’s Signature Date

During the application process, including testing and residential consideration, your name may be removed for consideration for any disqualifying reason.

AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

I ______hereby authorize and request,
Name of Facility: ______
Address: ______
______
to release confidential information, including personal, psychological, psychiatric, drug/alcohol, medical records and opinions, resulting from my contacts with the above to:
Name: Dana Dunklin
Title/Functions: Renascence, Executive Director
Address: 215 Clayton Street
Montgomery, AL 36104
Disclosure shall be limited to the following specific types of information:
Verification of absence of violent and/or sex related offenses
Use of this information shall be limited to the following purpose(s):
For the purpose of assisting in all phases of community programming, release, and
transitional planning.______
I understand that any cancellation or modifications of this authorization must be in writing, and that I have a right to receive a copy of this authorization. A photocopy of this authorization shall be as effective and valid as the original.
This authorization shall remain valid until my discharge from the Renascence Re-entry Community.
I furthermore release all parties stated here within from any legal liability resulting from the release of this information, with the understanding that all parties involved will exercise appropriate safeguards while using this information
Signature ______Date ______

Renascence, Inc.

Assisting in the transition of non-violent, male, ex-offenders from prison 215 Clayton Street

to a successful reintegration into the local community. Montgomery, Alabama 36104

Phone (334)

Verification of prospective resident’s status as a non-violent/non-sexual related offender

This form must be completed and signed by a Psychologist, Psychological Associate, Drug Program Specialist, Drug Treatment Counselor, or Classification Specialist.

I certify that a review of the prison record (including the Pre-Sentencing Investigation Report if

available) indicates that has not been convicted

Prospective Resident’s Name

of a violent or sexually related crime.

______

Prospective Resident’s Signature Date

______

Staff Name and Title Printed Date

Staff Signature

Renascence Re-Entry Community

Residency Contract

Date: Applicant Name:

Thank you for your interest in the Renascence Re-Entry Community, a transitional re-entry program for non-violent male offenders, who are approaching parole or probation.

This contract defines the mutual responsibilities of each partying developing, implementing and maintaining, and individualized program to assist the applicant in making a successful reintegration to the local community. Failure of either party to meet objectives specified in this contract may be cause for cancelling or renegotiating this contract.

Renascence agrees to provide structured housing in a safe and humane environment, sustenance, clothing, counseling, resource development, referral and other services to attain program goals.

Resident’s Agreement:

If accepted into the program you are responsible for abiding by the rules and regulation included in this contract.

I understand and agree that while a resident in the Renascence Re-entry Community I will be required to abide by the rules and regulations written by Renascence, Inc. and adhere to my individualized program plan. As part of my individualized program plan I realize that:

Upon arrival at the Renascence Re-entry Community I may be initially placed in a restrictive component of the program structure for a period of orientation. I will be expected to remain at the Renascence Community for thirty (30) day probationary period unless authorized to leave for employment or other authorized program purposes.

Social visits and recreational/leisure activities will be confined to the Renascence Re-entry Community or at Renascence Staff’s discretion

During this period that the use of motorized vehicles and cell phones will be prohibited.

The use of illegal drugs or alcohol is against the rules. All members of Renascence are expected to refrain from the use of alcohol and illegal drug use. The use of drugs or alcohol will result in the immediate dismissal from the program. Renascence staff randomly tests for drugs and alcohol use.

Attendance to mandatory self-help groups is required

I will be expected to contribute to the cost of my residence through payments (25% of gross income) to Renascence, Inc. and I agree to make such payments. I understand and agree that failure to make payments may result in my removal from the Renascence Re-entry Community.

I am expected to assume financial responsibility for my health care while a resident of the Renascence Re-entry Community

I will be required to abide by the conditions of parole supervision as imposed by the sentencing court or the Alabama Board of Pardons and Paroles; including the payments of fines and restitution and to follow the instructions of the parole officer

I will be expected to arrive at Renascence on the day of my release and that failure to do so could result in dismissal from the program.

There is a MINIMUM residency requirement time period of SIX MONTHS. Contingent on personal progress in achieving my individualized program plan, and with the proper approval of my supervising parole officer, I may be considered for successful discharge from the Renascence Re-entry Community before the minimum residency requirement time period

This is to acknowledge that I have received and read my copy of the Residency Contract, am familiar with and understand its contents, and agree to comply with its terms during my residency.

______

Resident Date

______

Renascence, Inc. Staff Representative Date

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