W.A.S.H. Community Membership Application

I. Organizational Information

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* 1. Company Name / DBA

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* 2. Legal Entity Name

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* 3. Owners of Record

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* 4. Select Type of Organization

Corporation

Partnership

Limited Liability (LLC)

Non-Profit Corporation

Nonprofit (other)

Unincorporated Entity

Other (specify)

Other (please specify)

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* 5. Year Founded

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* 6. Company Billing Address

Street:

City:

State:

Zip Code:

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* 7. Company Mailing Address

Street:

City:

State:

Zip Code:

Phone:

Website:

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* 8. Principal contact person

Full Name:

Title:

Phone Number:

Email Address:

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* 9. Will your organization attend the training workshops within 90 days of certification?

Yes

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* 10. Does applicant own or operate a licensed or certified addiction or mental health program or facility?

Yes

Other (please specify)

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* 11. Do any of the owners identified in this application have an ownership interest in or any sort of business relationship with a licensed, independent use, confirmatory lab?

Yes

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* 12. If owners have any ownership in any other businesses in the recovery industry please disclose here:

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* 13. Do you operate other types of housing?

Yes

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* 14. Specify type and facility:

II Management and Staff Information
All owners, managers and staff are required to register with the credentialing entity (W.A.S.H. Community). If the legal entity is a corporation with a large Board of Directors or is publicly traded as is owned by a broad body shareholders, then the CEO and CFO may register as "Owners of Record". For each contact entered, a unique email address is required and a contact phone number that will be directly answered by that contact.

Main switchboard phone numbers and general inbox addresses are not permissible in the contact section of this application.
Failure to list all owners, managers, and staff constitutes a fraudulent application that may result in denial and/or revocation of your certificate of compliance.

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* 15. Management

Street:

City:

State:

Zip Code:

Phone:

Full Name:

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* 16. Staff

Street:

City:

State:

Zip Code:

Phone:

Full Name:

III Standards, Code of Ethics, Dispute Resolution

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* 17. Do you maintain formal standards for the operation of your recovery residences?

Yes

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* 18. Do you maintain a code of ethics to which all members subscribe, or do your standards contain provisions equivalent to a code of ethics?

Yes

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* 19. Do you agree to adopt the W.A.S.H. Community Standard for Recovery Residences for all recovery residences operated by your organization?

Yes

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* 20. Do you have a defined process for resolving complaints from residents and the public?

Yes

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* 21. Do you maintain and follow procedures for logging and retaining records of complaints about your residences, and the manner in which they were resolved?

Yes

IIII Support for W.A.S.H. Community Mission

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* 22. Are you willing to fully participate in W.A.S.H. Community organizational activities?

Yes

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* 23. Are you willing and able to support W.A.S.H. Community-sponsored research initiatives?

Yes

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* 24. Are you willing and able to contribute financially to the operation of NARR by payment of applicable annual affiliate fees?

Yes

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* 25. Do you intend to conform to affiliate requirements which are enacted by W.A.S.H. Community for adoption by its affiliates?

Yes

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* 26. Do you agree to cooperate with W.A.S.H. Community in efforts to resolve complaints received by W.A.S.H. Community about the affiliate or about its individual members?

Yes

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* 27. Have you read and do you understand the residence certification requirements?

Yes

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* 28. Have you reviewed the health, safety and management requirements?

Yes

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* 29. Have you read, and do you agree to abide by the Code of Ethics?

Yes

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* 30. Have all responsible persons (see note) read, and signed, the Code of Ethics?

Note: A 'responsible person' is anyone in a position of authority or responsibility within the residence, including managers, house captains, senior residents, peer leaders and heads of household.

Yes

V Residences

General Information

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* 31. Residence Name

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* 32. County

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* 33. Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 34. Please select Type of Ownership

Owned by member

Leased from 3rd party

Leased from self, person or entity related to owner

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* 35. Please select Level of support

III

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* 36. Manager Name

Housing Capacity Information

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* 37. Type of structure

Single Family

Multi Family

Apartments

Condo

Number of Units

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* 38. Number of Bedrooms

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* 39. Number of Beds

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* 40. Number of Bathrooms

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* 41. Other space available?

Yes

Other (please specify)

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* 42. Pool available?

Yes

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* 43. Gender of Priority Population

Men

Women

LGBT

Veterans

Pregnant Women

Coed

Men with Children

Women with Children

Other (please specify)

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* 44. Do you welcome Medically Assisted Treatment in your residences?

Yes

(please specify type of)

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* 45. Is your residence abstinence based?

Yes

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* 46. Recovery Path

12 Step

Faith Based

Celebrate Recovery

SMART

Other (please specify)

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* 47. Is food included in the fees?

Yes

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* 48. Do you manage resident funds?

Yes

Other (please specify)

Costs

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* 1. Company Name / DBA

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* 2. Legal Entity Name

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* 3. Owners of Record

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* 4. Select Type of Organization

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* 5. Year Founded

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* 6. Company Billing Address

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* 7. Company Mailing Address

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* 8. Principal contact person

Question Title

* 9. Will your organization attend the training workshops within 90 days of certification?

Question Title

* 10. Does applicant own or operate a licensed or certified addiction or mental health program or facility?

Question Title

* 11. Do any of the owners identified in this application have an ownership interest in or any sort of business relationship with a licensed, independent use, confirmatory lab?

Question Title

* 12. If owners have any ownership in any other businesses in the recovery industry please disclose here:

Question Title

* 13. Do you operate other types of housing?

Question Title

* 14. Specify type and facility:

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* 15. Management

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* 16. Staff

Question Title

* 17. Do you maintain formal standards for the operation of your recovery residences?

Question Title

* 18. Do you maintain a code of ethics to which all members subscribe, or do your standards contain provisions equivalent to a code of ethics?

Question Title

* 19. Do you agree to adopt the W.A.S.H. Community Standard for Recovery Residences for all recovery residences operated by your organization?

Question Title

* 20. Do you have a defined process for resolving complaints from residents and the public?

Question Title

* 21. Do you maintain and follow procedures for logging and retaining records of complaints about your residences, and the manner in which they were resolved?

Question Title

* 22. Are you willing to fully participate in W.A.S.H. Community organizational activities?

Question Title

* 23. Are you willing and able to support W.A.S.H. Community-sponsored research initiatives?

Question Title

* 24. Are you willing and able to contribute financially to the operation of NARR by payment of applicable annual affiliate fees?

Question Title

* 25. Do you intend to conform to affiliate requirements which are enacted by W.A.S.H. Community for adoption by its affiliates?

Question Title

* 26. Do you agree to cooperate with W.A.S.H. Community in efforts to resolve complaints received by W.A.S.H. Community about the affiliate or about its individual members?

Question Title

* 27. Have you read and do you understand the residence certification requirements?

Question Title

* 28. Have you reviewed the health, safety and management requirements?

Question Title

* 29. Have you read, and do you agree to abide by the Code of Ethics?

Question Title

* 30. Have all responsible persons (see note) read, and signed, the Code of Ethics?Note: A 'responsible person' is anyone in a position of authority or responsibility within the residence, including managers, house captains, senior residents, peer leaders and heads of household.

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* 31. Residence Name

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* 32. County

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* 33. Address

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* 34. Please select Type of Ownership

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* 35. Please select Level of support

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* 36. Manager Name

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* 37. Type of structure

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* 38. Number of Bedrooms

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* 39. Number of Beds

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* 40. Number of Bathrooms

* 30. Have all responsible persons (see note) read, and signed, the Code of Ethics?

Note: A 'responsible person' is anyone in a position of authority or responsibility within the residence, including managers, house captains, senior residents, peer leaders and heads of household.