Participant Agreement Form

First Name *

Middle Initial *

Last Name *

Terms of Participation

I will complete a Substance Abuse Questionnaire before intake and at six months intervals thereafter while participating in MRT.

I will sign consent forms to allow parole or probation officers, SCRIMP staff members and friends or family members of my choosing to share relevant information regarding my ongoing progress.

I will not share information about other clients or mentors without their written consent unless necessary to prevent eminent and serious harm to myself or another person.

I will do my best to set and meet weekly goals in the Moral Reconation Therapy (MRT) program.

I will meet with a SCRIMP mentor individually or in a group for at least four hours monthly and for at least 6 months.

As a result of making adequate progress in MRT and having no unexcused absences, I will receive a monthly $20 bus pass and a weekly $10 Dillon’s or Walmart gift card to be used for gasoline, food, and personal care items or cell phone service. I understand that receipts for these purchases must be submitted to the Program Manager in order to be eligible for future gift cards.

I agree to comply with all terms and conditions of my parole or probation supervision. I will not ask or expect SCRIMP staff, mentors or partners to tolerate or cover up any violations of the law or of these terms and conditions.

I will not ask SCRIMP mentors or other Seeds of Hope volunteers for money or other material items. I understand that all such needs should be brought to the attention of the MRT Facilitator or a member of the Seeds of Hope Board of Directors and that they will do everything in their power to fill those needs.

I understand and agree to all of the above terms: *

I agree

I disagree

Date *

Year

Month

Day

Email Address *

Phone Number