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Kokopelli Group Home, LLC
Kokopelli Group Home, LLC Rules at a glance. To be complemented by the full agreement. Any criminal activity (on or off the facility) is not acceptable and will result in discharge. If you have a warrant from a legal authority, you must disclose this information immediately. NO ALCOHOL OR CONTROLLED SUBSTANCES are permitted while you are in our program. All medications, including pain pills, psych meds, aspirin, Advil, cold, flu, sinus, etc. must be disclosed to Kokopelli. Kokopelli can test any Program Participant at any time for alcohol or controlled substances. Television, Computer, Radio, and Telephone are for you and the other Program Participants to enjoy, and must be acceptable by the other Program Participant's. Do not have the noise levels loud to disturb the other program participants and limit your use so other participants can enjoy. NO FIGHTING, THREATENING, or COMMITTING VIOLENCE against another. STEALING AND LYING will not be tolerated. Go get a Food Box. VANDALISM AND INTENTIONAL PROPERTY DAMAGE will not be tolerated ALL PROGRAM PARTICIPANTS MUST SIGN OUT AND SIGN IN. It does not matter if you are on parole, probation or not. ALL Visitors and Guests must register with the Manager and Sign In / Out, before access. FAILING TO COME TO THE PROGRAM FACILITY WITHOUT NOTICE IS A DIRECT VIOLATION. The DIRECTOR must approve any passes in advance and be on file with Kokopelli. Your Legal Supervisor (Parole/Probation Officer) must also Approve all Passes. THERE IS A CURFEW THAT MUST BE ADHERED TO. You must have a curfew extension if you work late or have a unique situation requiring you to stay out past the curfew. THERE ARE NO FIRES OR SMOKING IN THE FACILITY. NO ADDITIONAL APPLIANCES ARE PERMITTED IN THE ROOMS. No program participant is permitted to enter the area of another program participant. All vehicles must be in running condition and have current registration and proof of insurance. YOU ARE EXPECTED TO HELP WITH GENERAL HOUSEHOLD UPKEEP AND CLEANING. This includes cleaning up after yourself and doing the ASSIGNED CHORES. Maintain good personal hygiene. Only current Program Participants are permitted use the Telephone and Computer. All Kokopelli Group Home, LLC Program Participants must have a job or work community service. No Participant is permitted to stay at the house and become sedentary. You must review your integration or recovery program with the house manager at least one (1) time per week. Kokopelli Group Home, LLC requires a minimum of a one (1) week written notice to leave the program. If you do not the Deposit may be Forfeited. If your Legal Supervisor gives you permission to Leave the Program, you should take the 1 week notice in account. Limit your personal property to what will be accommodated by your assigned area. Secure your valuables. Your property is your responsibility and if you do not assume that responsibility then any loss is your burden. Kokopelli Group Home, LLC nor its agents are responsible for any loss or damage to your property. Kokopelli_Group_Home-Rules_at_a_Glance 5/15/2011 KOKOPELLI GROUP HOME, LLC. PROGRAM PARTICIPANT AGREEMENT By this agreement, made and entered into on _________________________________________[date], between _________________________________________, referred to as “program participant,” and Kokopelli Group Home, LLC (KGH) aka Kokopelli Recovery Program, demises and permits to Program Participant by KGH, the Admission to a Program solely for the purpose of transitioning into society and advanced recovery from an alcohol or substance abuse located at a facility known as Kokopelli Group Home, LLC, in Mesa, Maricopa County, Arizona. This is not an agreement for occupancy or tenancy the facilities are solely for the purpose of a recovery program service for the participant, to be used by program participant during the period the participant is allowed in the recovery program and for no other use or purpose whatever, for a term of a minimum of 90 days beginning on _________________________[date] at a program fee of $520.00 * per month (plus any applicable taxes), payable in advance, prorated at $17.45 (plus any applicable taxes) * per day if necessary, during the entire term of this agreement, to KGH in Mesa, Maricopa County, Arizona, or to any other person or agent and at any other time or place that KGH may designate. Program participation is Friday through Thursday. If the Participant begins the Program on a day prior to Friday, the Program Fee will be prorated to Friday. The Program Fee is due on first day of the month by 8:00 pm, unless prior arrangements are approved by KGH. An alternate payment plan may be $120.00 per week plus applicable taxes, due on each Friday at 8:00 PM. The normal week is from Friday to Thursday. Any payments after that time will be considered delinquent and late fee of up to five percent (5%) per day or termination of this agreement may apply. All payments are to be by “Money Order” or “Cashier Check”, with the Payee designated as “Kokopelli Group Home, LLC”. Kokopelli does not accept Personal Checks. Participants that get behind in the Program Service Fees will be required to accept a Power of Attorney to have their paychecks turned over to Kokopelli Group Home, LLC and a budget amount will be administered to the Participant, until the Program Service Fees and Security Deposit are paid in full. If the Participant refuses to accept the Power of Attorney, then this agreement is automatically terminated and the Participant must leave the Program immediately. Kokopelli Group Home, LLC can only accept persons that are American with Disabilities Act (ADA) Qualified and are fully ambulatory. Kokopelli cannot accept non-ambulatory individuals that have a physical or mental disability that impairs a "major life activity," such as walking, seeing, hearing or speaking. All individuals must be capable of self preservation and evacuation in the case of an emergency. It is further mutually agreed between the parties as follows: SECURITY DEPOSIT On the execution of this agreement, program participant deposits with KGH $120.00 *, receipt of which is acknowledged by KGH, as security for the faithful performance by program participant of the terms of this agreement, to be returned to program participant, without interest, on the full and faithful performance by program participant of the provisions of this agreement. The Security Deposit is not the last program fee amount and will be returned after all Kokopelli property is accounted for, including all bedding, hangers and other property. The bedding must be cleaned, the bed made, and the room in clean condition when the participant leaves the program. The deposit is not refundable if you relapse or are detained by a legal authority. KGH requires one week written notice, beyond the first month, by the program participant to leave the program or the security deposit is forfeited. This Security Deposit of $120.00 is in addition to the monthly Program Fee. TERMINATION OF AGREEMENT The Program Participant shall abide by all rules and policies of Kokopelli Group Home, LLC. If the Program Participant violates these rules and policies then the Program Participant agreement is subject to termination and the time is expired, immediately. The Program Participant agrees that upon termination of this agreement to immediately vacate the premises of Kokopelli Group Home, LLC and remove the Program Participant’s personal property immediately. All Kokopelli Group Home, LLC property is to remain on the premises and unauthorized removal of Kokopelli Group Home, LLC property is considered a violation of the prevailing laws of Arizona. The Program Participant agrees that the Recovery Program is a service and is not an occupancy or tenancy agreement and therefore the Program Participant has no rights under the Arizona Landlord Tennant Act (Arizona Revised Statutes Title 33, Chapter 10) or any other provisions for occupancy or tenancy. If this agreement is terminated by Kokopelli Group Home, LLC, the time is expired and the Program Participant must vacate the facilities immediately or be in violation of ARS 13-1504 Criminal Trespass in the First Degree or 13-1502 Criminal Trespass in the Third Degree or both. Any supervisory authority will be notified immediately of the termination and discharge. ASSIGNMENT AND SUBLETTING Program participant shall not assign this agreement to another person. There is no subletting as the Kokopelli Recovery Home is not a rental, but a service to assist the program participants to transition into society and continue in their recovery. ENTRY FOR INSPECTION, REPAIRS, AND ALTERATIONS KGH shall have the right to enter any area of the Kokopelli Group Home, LLC facility and all rooms therein for inspection at all reasonable hours and whenever necessary to inspect, make repairs and alterations of the Kokopelli Home facility, or to clean the facility. __________ Participant Initial KOKOPELLI_PROGRAM_PARTICIPANT_AGREEMENT Page 1 of 8 12/9/2008 © 2008 Kokopelli Group Home, LLC UTILITIES/SERVICES Electricity, gas, telephone service, cable or satellite TV, and other utilities are furnished as a part of this agreement. Any issues with any service will be resolved by Kokopelli Group Home, LLC. You are expected to conserve the resources. Do not open any windows or block any doors open, without the notification and approval of the manager or Kokopelli Management. There is to be no long distance phone calls or acceptance of collect calls. There is to be no pay television programs. The laundry facilities are to be conserved. Use only the proper amount of detergent, proper washing machine setting, and use the “clothes line” for drying your clothes, whenever possible. You must take reasonable length showers and not run the water for lengthy periods of time. Any violation of this conservation effort may result in having services terminated. FURNISHINGS Refrigerator, washer, dryer, couches, chairs, dining table, toaster, bed, chest, television, computer, and other furnishings are a part of this agreement. No furnishing is to be added or moved without the express permission of Kokopelli Group Home, LLC. There is to be no personal refrigerators, heaters, heating blankets/pads, etc. in the rooms. Personal small fans and small TV’s are permitted and are to be turned off when not in the room. Any damage to the furnishings will be assessed. Do fold your clothes and do not overfill the dresser drawers. Do not place uncovered food in the refrigerator, your assigned area or other shelves. PROGRAM PARTICIPANT REFERRAL If the program participant provides a referral for another program participant, the program participant will be compensated with a $10 reduction of program fees on the 2nd, 3rd, 4th, and 5th month the referred program participant has satisfactory program participation. If the referring program participant or referred program participant terminates their program, then this referral fee will no longer be in effect. REPAIRS, REDECORATION, OR ALTERATIONS KGH shall be responsible for repairs to the interior and exterior of the Kokopelli Group Home, LLC facility, provided, however, repairs required through damage caused by program participant shall be charged to program participant as additional program fees. It is agreed that program participant will not make or permit to be made any additions, improvements, or changes in the facility. ANIMALS Program participant shall keep no domestic or other animals (aka pets, dogs, cats, birds, fish, lizards, etc.) in or about the facility or on the premises. This means that no pets are allowed. WASTE, NUISANCE, OR UNLAWFUL USE Program participant agrees that he will not commit waste on the premises, or maintain or permit to be maintained a nuisance on the premises, or use or permit the premises to be used in an unlawful manner. The program participant further agrees to abide by all sections of this agreement, clean up after themselves, and perform the assigned Chore List as a part of the agreement. PARKING SPACE Program participant use parking space on a first come- first served basis. No inoperable vehicles are allowed on the premises. All vehicles must be properly licensed and insured. Kokopelli must have a copy of your current registration and insurance. If you are restrained from operating a vehicle, you must inform Kokopelli Group Home, LLC of this restraint and provide proof of reinstatement prior to your operating any vehicle. PROGRAM PARTICIPANT RIGHTS You may submit grievances without restraint or retaliation and have grievances considered in a fair, timely, and impartial manner. If you are discharged for a flagrant violation, your request will be reviewed and a decision rendered within 72 hours of Kokopelli receiving the written grievance. Your information and records will be kept confidential to Kokopelli Group Home, LLC Management. You will have the right to have privacy in correspondence, communication, visitation, and financial affairs. You have the right to review your own information record. You will be free from abuse and exploitation. You may associate with individuals of the Program Participant’s choice, receive registered visitors, and make telephone calls during the hours established by Kokopelli Group Home, LLC as outlined and described in this agreement. Note: all visitors are required to register and sign in and to follow the same guidelines as outlined in this agreement. No visitor is permitted the use of Kokopelli facilities (i.e., Computer, phone, etc.). If any visitor is under legal supervision, they must immediately disclose this information to Kokopelli Group Home, LLC management and is not permitted on the premises as that presence is a violation of the supervisory authority. If a visitor is found to not be in compliance with this agreement, the visitor will be discharged from the facility. DEFAULT If program participant defaults in the payment of program fees or any part of the program fees at the times specified above, or if program participant defaults in the performance of or compliance with any other term or condition of this program agreement or of the regulations attached to and made a part of this agreement, which regulations shall be subject to occasional amendment or addition by KGH, the agreement, at the option of KGH, shall terminate and be forfeited, and KGH may reenter the facility premises and retake possession and recover damages, including costs and attorney fees. Program participant shall be given verbal __________ Participant Initial KOKOPELLI_PROGRAM_PARTICIPANT_AGREEMENT Page 2 of 8 12/9/2008 © 2008 Kokopelli Group Home, LLC or written notice of any default or breach. Termination and forfeiture of the agreement shall not result if, within one (1) day of receipt of such notice, program participant has corrected the default or breach or has taken action reasonably likely to effect correction within a reasonable time. If the program participant is late in paying the program fee, there is up to a five percent (5%) per day late charge or termination of this agreement. The program participant must make arrangements with the KGH to continue the program past the 3 day time period. Any default will forfeit the deposit to the benefit of KGH and may terminate this agreement. DESTRUCTION OF FACILITY AND EMINENT DOMAIN In the event the facility are destroyed or rendered unusable by fire, storm, or earthquake, or other casualty not caused by the negligence of program participant, or if the premises are taken by eminent domain, this agreement shall be at an end from such time except for the purpose of enforcing rights that may have then accrued under this agreement. The program participant may transfer to another KGH facility to continue in the recovery program, if available. The program participation shall then be accounted for between KGH and program participant up to the time of such injury or destruction or taking of the facility, program participant paying up to such date and KGH refunding the program fee collected beyond such date. Should a part only of the facility be destroyed or rendered unusable by fire, storm, earthquake, or other casualty not caused by the negligence of program participant, the program shall abate in the proportion that the injured part bears to the whole program premises. The part so injured shall be restored by KGH as speedily as practicable, after which the full program fee shall recommence and the agreement continue according to its terms. Any condemnation award concerning the premises shall belong exclusively to KGH. CRIME FREE PROGRAM PARTICIPANT AGREEMENT In consideration of the execution of a program participation agreement of the Kokopelli Group Home, LLC Program Participant Agreement, Kokopelli Group Home, LLC and program participant agree as follows: 1. Program participant, any members of the program participant's household or a guest or other person under the program participant's control shall not engage in criminal activity, including drug related criminal activity, on or near the said premised... "Drug related criminal activity" means the illegal manufacture, sale, distribution, use, or possession with intent to manufacture, sell, distribute, or use of a controlled substance (as defined in Section 102 or the Controlled Substance Act (21 U.S. C. 802)). 2. Program participant, any member of the program participant's household or a guest or other person under the program participant's control shall not engage in any act intended to facilitate criminal activity, including drug related criminal activity, regardless of whether the individual engaging in such activity is a member of the household, or a guest. 3. Program participant or members of the household will not permit the dwelling unit to be used for, or to facilitate criminal activity, including drug related criminal activity, regardless or whether the individual engaging in such activity is a member of the household, or a guest. 4. Program participant, and member of the program participant's household, or a guest or another person under the program participant's control shall not engage in the unlawful manufacturing selling, using, storing, or giving of a controlled substance as defined in A.R S. 13-3451, at any locations, whether on or near the dwelling unit premises or otherwise. 5. Program participant, any member of the program participant's household, or a guest or another person under the program participant's control shall not engage in any illegal activity, including prostitution as defined, in A.RS. 13-3211, criminal street gang activity as defined in A.R.S 13-105 and 13-2308, threatening or intimidating as prohibited in A.R.S. 13-1202, assault as prohibited in A.RS. 13-1203 including but not limited to the unlawful discharge of firearms, on or near the dwelling unit premises, or any breach of the program participant agreement that otherwise jeopardizes the health, safety and welfare of the Kokopelli Group Home, LLC or other program participant or involving imminent or actual serious property damage. 6. VIOLATION OF THE ABOVE PROVISIONS SHALL BE A MATERIAL AND IRREPARABLE VIOLATION OF THIS AGREEMENT AND GOOD CAUSE FOR IMMEDIATE TERMINATION OF THE PROGRAM. A single violation of any of the provisions of this added addendum shall be deemed a serious violation and a material and irreparable non-compliance. It is understood that a single violation shall be good cause for immediate termination of the agreement. Unless otherwise provided by law, proof of violation shall not require criminal conviction, but shall be by a preponderance of the evidence. 7. In case of conflict between the provisions of this agreement and any other provisions of the program participant addendums, the provisions of this agreement shall govern. If you have conditions ordered by a legal entity, you must provide a copy of those conditions to Kokopelli Group Home, LLC. 8. This CRIME FREE PROGRAM PARTICIPANT AGREEMENT SECTION is incorporated into the PROGRAM PARTICIPANT AGREEMENT executed or renewed this day between Kokopelli Group Home, LLC, Program Participant, and the Mesa Police Department. KOKOPELLI GROUP HOME, LLC FACILITY RULES The purpose of the Kokopelli Group Home, LLC is to provide a safe and healthy environment to participate in a clean and sober recovery program, and achieve a self-fulfilling lifestyle. The following rules are necessary to achieve this purpose and still promote personal responsibility: There are "Flagrant Violations" that can result in IMMEDIATE termination of Program Participation at the Kokopelli Group Home, LLC. __________ Participant Initial KOKOPELLI_PROGRAM_PARTICIPANT_AGREEMENT Page 3 of 8 12/9/2008 © 2008 Kokopelli Group Home, LLC Reporting violations to any of theses rules to Kokopelli Management, is required. You may report the incidents by verbal or written notification. Kokopelli also has an email address that you can log into and report the incident via a “silent witness” program. The URL Address is http://webmail.west.cox.net/ , the User ID is kokosilent, and the password is kokopelli1. There is no reverse identification for us to know who sent the message. If you know of a violation and do not report the violation, you become an accessory to the violation, and therefore may suffer consequences. These rules are in effect to comply with the City of Mesa and to maintain a safe recovery home. Violating the Crime Free Agreement Section is reason for Immediate Termination of the program. This agreement will be Rigidly Enforced. If you have a warrant from a legal authority, you must disclose this information immediately to Kokopelli Group Home, LLC. You are required to check with any potential jurisdictions to determine your legal status. If the warrant is for a fine that you have not paid, then you must make payment arrangements with the legal authority. No Alcohol or Controlled Substances are permitted on the premises, inside or outside. If you have a prescription for a drug, you must disclose to the Kokopelli Group Home, LLC management with proof of the prescription. If the prescription is to be dispensed and you would like the prescription controlled, please discuss and arrange with Kokopelli Group Home, LLC management. All information will be documented to eliminate any misunderstandings. If you bring alcohol or a controlled substance on the facility, expect to pack your belongings and leave the Kokopelli Group Home, LLC Program immediately. If you are aware of someone violating this rule, you are expected to report the incident to Kokopelli Management. All medications, including pain pills, psych meds, aspirin, Advil, cold, flu, sinus, etc. must be disclosed at intake and during the program participation. All medications will be kept, and secured (preferably in a lockbox). All medications must be dispensed according to the instructions on the prescription bottle. Any Rx or "over the counter" medications that have all unreadable labels will be disposed of. Failure to disclose medications during intake or during your continued program participation will cause you to be discharged. If you overmedicate you may be required to go to a detoxification center or medical facility until you are at a normal status, and released by a medical attendant. Kokopelli may then determine your return into the Kokopelli Program. You will be required to attend substance abuse or other related counseling and provide KGH proof of attendance. Kokopelli can test any Program Participant at any time for alcohol or controlled substances. If someone in the program feels you are using, we may test you, unless it is obvious, and inspect your property. Kokopelli will always ask you if you have been using. If you affirm, then we will recommend you go to the detox center. If you refuse, we will dismiss you from the Program. If you deny then we will test you. If you test positive you will owe us $20 for each test and you must go to a detoxification center or be discharged. If you are negative then you will not owe the fee and the issue is closed. In any case the test should be viewed as a positive resolution, not a negative issue. All program participants and staff are subject to random breath and urine tests. Refusal to test is subject to immediate termination of the Program Agreement. Television, Computer, Radio and other entertainment are for you and the other Program Participants to enjoy, and must be acceptable by the other Program Participant's. Do not have the noise levels loud to disturb the other program participants. If you are requested to lower the noise level, you must do so immediately. You might need to get a pair of headphones for your personal enjoyment if the noise disturbs other program participants. In general, these noises should not be permitted beyond 30 minutes past the curfew and should remain off until the next day at a reasonable time but Kokopelli Group Home, LLC's management may approve if it does not disturb the other Program Participants. This rule includes the Kitchen and other common area usage. You may have a personal TV, computer, radio or other entertainment, provided you follow the rules and policies within this paragraph. There will be no loud music played inside or outside, abusive noise, or obscene language or jesters inside or outside the Kokopelli Facility at any time. If you are not working, then the Computer, TV and radio is off limits. You will not be allowed to sit at the house and watch TV while you are not employed or performing community service. NO FIGHTING, THREATENING, or COMMITTING VIOLENCE against another. If there is a dispute, bring to Kokopelli Group Home, LLC's attention. All disputes will be resolved, PEACEFULLY. If you violate this rule, you will be dismissed immediately. Stealing will not be tolerated. This includes any KGH or other participant’s property and food. Stealing is grounds for IMMEDIATE Termination of the Program Agreement. If you have valuables or money, you are responsible to secure your property. Kokopelli is not responsible for your personal property. If you need food, do not steal it. You can get over to a food box location almost every day and get a food box. All you have to do is get up and go get it. Lying will not be tolerated. Lies found on your intake paperwork or otherwise during the course of your Program Participation are grounds for IMMEDIATE Termination of the Program Agreement. Vandalism and intentional property damage will not be tolerated, and is grounds for IMMEDIATE Termination of the Program Agreement. __________ Participant Initial KOKOPELLI_PROGRAM_PARTICIPANT_AGREEMENT Page 4 of 8 12/9/2008 © 2008 Kokopelli Group Home, LLC Nothing is permitted to be placed on the walls or ceilings (taped, stapled, or nailed). There are no markings of any kind to be made on the walls or ceilings. There may be a bulletin board/marker board for each program participant. All decorations must be approved by the Kokopelli Group Home, LLC and if they become fixed to the facility, they are to become the property of Kokopelli Group Home, LLC. Any criminal activity (on or off the facility) is not acceptable, and is grounds for IMMEDIATE Termination of the Program Agreement. Signing Out and In-All program participants must sign out and sign in. This rule must be applied to all program participants whether or not they are on legal supervision. The time signed out (including AM or PM), intended location, expected return time (including AM or PM), and actual return time, when you get back, must be completed. If you are going to be returning beyond your expected return time, you must call the manager to inform of the new return time. The manager must approve this return time. Failing to come to the program facility without notice is a direct violation, and is grounds for IMMEDIATE Termination of the Program Agreement. There is a curfew that must be adhered to: Sunday through Thursday 10:00 pm. Note: 8:00 pm if the Program Fee and Security Deposit is not current. Normal departure time is no earlier than 4:00 am daily for the purpose of curfew, and for work only. Friday and Saturday 12:00 am. Note: 10:00 pm if the Program Fee and Security Deposit is not current and possibly 8:00 pm if on restriction. • If the curfew is not adhered to, then this agreement is subject to immediate termination. You must insure that you have the ability to return to the Kokopelli facility in a timely manner before you leave the facility. If you do not have a return plan and do not return by the expected time, you will be in violation of this agreement. • You must make prior arrangements with Kokopelli Group Home, LLC management for any extended absences. If you must be away from the facility for more than 12 hours, or beyond the curfew, you must notify Kokopelli Group Home, LLC and be approved, not by just calling and leaving a message. All arrangements will be documented to eliminate any misunderstandings. • Curfew can be changed on a case by case basis. After 30 days participation, an overnight pass may be requested. The first pass is limited to 24 hours. Future requests may be made for up to 48 hours. There may not be more than three (3) overnight passes per month. You must leave a contact number and your assigned chore must be completed before leaving on any overnight pass. If you have a job that the work hours are beyond the curfew hours, then a Curfew Extension form must be completed and approved by Kokopelli Group Home, LLC management. Note: All passes and curfew extensions must be pre-approved by the applicable parole, probation, legal supervision and Kokopelli Management. There are no exceptions even if not on active legal supervision. • New program participants are normally restricted to the Kokopelli Group Home, LLC facility for the first two (2) days. If you must leave for any reason, except work, you must be accompanied by another program participant. If you are going to work, you must come to the facility immediately after work. If the Program Participant is entering Kokopelli Group Home, LLC from detox clinic, this restriction may be extended. If KGH feels the restriction is to be implemented, then the Restriction Agreement becomes a part of this Program Agreement. There are no Fires or Smoking in the Facility. This includes candles, incense, and smoking anywhere in the house. Smoking is permitted on the Back Patio no closer than 10 feet from the door entrances. The Ash Trays must be used; no cigarette butts or other tobacco products are to be thrown in the yard. No program participant is permitted to enter the area of another program participant unless accompanied by another program participant occupying that room, and notification to the Developmental Advocate. Other than the Developmental Advocate, being in another program participant’s area is grounds for immediate termination of the program agreement. Rooms with key locks. Selected Kokopelli rooms have key locks. These are special keys that only you and your roommate have (The manager has a complete set in case of emergency). The doors can only be locked from the exterior. You must carry your key with you and not lock the room unless you have verified that your roommate has the key. There is a $5.00 deposit for the key, which will be returned when the key is returned to Kokopelli. All room occupants must have paid the key deposit. If not all occupants have paid the key deposit, then no key can be issued to the participant. If you are locked out of your room then you must wait for the manager or your roommate to open the door. Do NOT make a forced entry No keys will be issued to anyone who is not current with the Program Fees. There are no weapons of any kind permitted on the Kokopelli Group Home, LLC facility. This is grounds for immediate termination of the Program Agreement. You must comply with any and all community and facility (Kokopelli Group Home, LLC) association Rules. __________ Participant Initial KOKOPELLI_PROGRAM_PARTICIPANT_AGREEMENT Page 5 of 8 12/9/2008 © 2008 Kokopelli Group Home, LLC Be a Good Neighbor. If you see a neighbor that may need help, please ask if you can help, and expect no more than gratitude in return. All vehicles must be in running condition and you must present current registration and proof of insurance for our files, or be immediately removed from the property. Any vehicle repairs must be minor, and the work area cleaned each day, if the repairs take more than one day. No extensive repairs are permitted on the facility or Public Street in the proximity of the facility. There is to be no car washing on the KGH facility. You must use a local car wash facility or other location. All driving must be safe and courteous. Careless and reckless driving is not permitted. Violation of this could result in immediate termination of your Program Agreement. Littering on the Kokopelli Facility or surrounding neighborhood is not permitted. Put cigarette butts in the ashtrays that are provided, not on the ground. Do not put your cigarettes out on the building structure. Loitering around the Kokopelli facility or neighborhood is not permitted. This may cause concern for our neighbors, and you may be subjected to trespassing charges by the local authorities. Loitering in the front area is generally not permitted. We want to be good neighbors and not disturb our other neighbors. You must be properly and appropriately dressed when you are outside of the Kokopelli Group Home, LLC facility. When inside the facility you must wear a shirt (pants or shorts too) while in all common areas. If you are relaxing on a couch or chair, please put a towel behind your head. There is to be no eating of meals or snacks in the assigned rooms. All liquids must be clear (i.e., water) in the assigned rooms. Any colored liquids (i.e., coffee, tea, soda, etc.) must be consumed in the common areas (i.e., kitchen, living room, etc). Be a Good Program Participant. Please consider your fellow program participants for all actions and activities. Clean up any messes you make, immediately, this includes dishes and cups. Keep your personal area and the facility clean and provide a quality environment for yourself and the other program participants. Be courteous and respect other program participants. Keep your use area neat and orderly, and make up your sleeping quarters every day. All dirty clothes are to be placed in a clothes hamper or bag, and all trash picked up. Use an air freshener if needed. You are expected to help with general household upkeep and cleaning. The Chores will be assigned to each program participant. These chores must be performed. Kokopelli Management may request additional cleaning. Refusal to clean up after yourself or do any assigned chore in a timely manner may result in termination of the program agreement. If you spill something you must clean it up immediately to equal or better than the condition it was. Do not stare at the mess and walk away, clean it up. Maintain good personal hygiene. You are expected to be clean and take a shower regularly. Guests are permitted to visit at the facility in only the common areas and not in the program participant's use area. Guests must register with the Manager and are required to present a valid picture ID (which will be copied and attached to the registration). If the visitor denies this process, then the visitor will be denied access and required to leave the facility premises immediately or be charged with trespassing. All guests must Sign In and Out. Overnight guests are not permitted. In general a guest can visit for 3 hours, 2 times per week. Any longer or more frequent visitations must be approved by the Manager. The number of guests should be no more than 2 at a time, and the guest(s) should be an occasional visitor, not a daily visitor . All guests that do visit are required to follow all rules and agreements that the program participant is obligated to follow. All guests must leave by the curfew time and not arrive prior to 7:00 AM. There are no exceptions. The program participant is responsible for any guest's actions and activities. This rule and policy is enforced to protect all Program Participants and the Kokopelli facility. Sexual or Pornographic activity is not permitted on the Kokopelli Group Home, LLC facility, including the computer. Telephone use. Only current Program Participants are permitted telephone use. Please limit your call length to 5 minutes and limit the number of calls. If someone is waiting to use the telephone, please make your call short so the other person can use the telephone. If another call comes in, you must “click over” and answer that call. If the call is for another program participant while you are on the phone, please ask if the call is urgent. If the call is urgent then let your party know and turn the phone over to the other program participant. If the call is not urgent, then please take a message for the program participant. The house phone is to remain in the interior common areas at all times. Do not take the phone outside or in your room. If you violate the phone use rule, you may be restricted to use of the phone. There are no telephones outside of the common areas permitted to be connected to the Kokopelli phone system. You may have a personal cell phone, but there are to be no phone usage beyond the 30 minute curfew limitation. This rule is in effect to prevent disturbing other program participants, and is not to be violated or phone privileges will be suspended. Computer use. Only current Program Participants are permitted computer use. The computer is available for your personal use. There are training programs installed to help you learn how to use a computer. Please limit your use. If another program participant is waiting to use the computer, please complete the task you are doing and allow the other program participant to use the computer. There may be a sign-up sheet for the computer use. No pornographic, gaming, or __________ Participant Initial KOKOPELLI_PROGRAM_PARTICIPANT_AGREEMENT Page 6 of 8 12/9/2008 © 2008 Kokopelli Group Home, LLC illegal activity is permitted on the computer. The computer is for personal use, business use is NOT Permitted. There is to be no downloading of music or video files without the express written authorization by the authors. This is in violation of Federal Laws (U.S. Digital Millennium Copyright Act). Printing should be limited to 2-5 pages per day. This is a privilege and will not be abused. Follow the computer usage rules. Do not give the User ID and Password to any other person. Violation of any computer rules will result in suspension of your computer access. The computer use is limited to only those Program Participants that are current with their fees and are not on restriction. You may have a personal computer, provided your program fees are current, but there are to be no computer usage beyond the 30 minute curfew limitation. This rule is in effect to prevent disturbing other program participants, and is not to be violated or computer privileges will be suspended. The computers are maintained after curfew and access may be unavailable. All information can be stored on a “DATA” designated drive. All other information may be removed during maintenance. Report Crime. If you see a possible criminal activity, please report to the police immediately and / or Kokopelli Group Home, LLC management. You may call as a Silent Witness if you are uncomfortable, but do report the criminal activity. New program participants should attend a minimum of three (3) meetings per week for the first 4 weeks. Program participants should find a sponsor within 30 days. This is a minimum requirement. All meetings must be verifiable and a Meeting Form is provided to document the activity. New participants are expected to arrange for counseling at a behavioral health clinic. Continuing participants may also be requested to enroll in behavioral health clinics, as deemed necessary. Continuing Program participants are expected to attend (2) AA and / or NA/CA meetings per week, have a sponsor and/or be involved in ongoing counseling for those conditions that impact your situation. All meetings must be verifiable. This can be discussed and adjusted with the approval of Kokopelli Group Home, LLC management. All program participants may be required to attend a Kokopelli Group Home, LLC meeting on the last Sunday of each month, or as scheduled by Kokopelli management. All Kokopelli Group Home, LLC Program Participants must have a job or work community service. No Participant is permitted to stay at the house and become sedentary. You are required to be employed full time, and you are not permitted to quit a job without first discussing it with the house manager and Kokopelli Group Home, LLC, (employment status will be verified periodically). There are certain types of employment that are not allowed (i.e., cab driving, working in bars, clubs, or places that sell alcohol). You must speak with the house manager prior to accepting employment with any place. You are not permitted to stay at the facility if you are unemployed. You must actively seek employment and bring back proof of your job search to the manager. If you become ill and claim that you cannot work or perform community service, then proof will be required by Kokopelli Group Home, LLC management, and you may need to relocate to another recovery program. You must continue to maintain the Program Fees as current. Any Kokopelli Group Home situation that requires police involvement must be discussed with the house manager and/or Kokopelli Group Home, LLC before the police are called, (any police involvement without house manager approval will be grounds for discharge). Any medical conditions and/or injuries must be brought to the attention of the house manager and/or Kokopelli Group Home, LLC. If there is an emergency, call 911, and then notify the house manager and/or Kokopelli Group Home, LLC immediately. There is no sharing of clothes, personal property, loaning money, borrowing vehicles, including automobiles and bikes by either staff or program participants permitted at any Kokopelli Group Home, LLC facility. Normally if you “loan” money, you just gave the person the money and you alone must accept the consequences. This rule is in effect to prevent issues for loss or damage to property. If someone needs money or cigarettes, then insist they work. You must review your integration or recovery program with the house manager at least one (1) time per week. This review does not count as a visit to discuss your program while paying the fees, unless the house manager chooses to do so. Kokopelli Management will review the weekly status to insure that you are in compliance with any conditions that may be in effect by either Kokopelli or the legal system. Kokopelli Group Home, LLC requires a minimum of a one (1) week written notice, beyond the first month and cleaning your area and bedding, if you intend to leave the Recovery Program. Be responsible and courteous to us and others, and not just walk off your job or leave your program. This notice will insure the refund of your deposit and the best possible references for future programs. If you leave the facility without notice or there is a discharge for flagrant violation of this agreement or the rules there is no refund of the deposit. PERSONAL PROPERTY We are a recovery facility for those that desire to make a new start on their life. When you begin participating in our program you will probably bring your personal property with you. Please limit the property to what will be accommodated by your assigned area and put your identification on your property. If you have an extensive amount of property, you must make arrangements to have it stored at another location. If for some reason, your participation agreement is terminated or you relapse and do not return to our facility, Kokopelli management will immediately pack your property and store it for a maximum of 30 days. __________ Participant Initial KOKOPELLI_PROGRAM_PARTICIPANT_AGREEMENT Page 7 of 8 12/9/2008 © 2008 Kokopelli Group Home, LLC If you decide to leave the Recovery Program, you are required to give KGH notice so we can make arrangements for someone to fill your vacancy in our program. If you leave without notice you will be assessed for the day you left the facility and the security deposit will be forfeited. There is a packing fee of $20.00 or more, depending on the amount of property, and a minimum daily storage fee of $3.00 per day, beginning with the first day of storage, for any reason including relapse or arrest. You will also be assessed a fee for cleaning your area and bedding (approximately $10.00). These fees must be paid prior to your claiming your personal property. If you do not claim your personal property within 30 days, then the property will be donated to a charity or other institution or agency. If any other fees are due to Kokopelli Group Home, LLC (i.e., Program Fees, etc) then those fees must be paid in full prior to your moving back into a Kokopelli facility. We will attempt to collect from those fees via the legal system, if you do not make arrangements and keep the arrangements. We will also post the debt with a credit agency or on the Internet until the debt is paid in full. Kokopelli Group Home, LLC nor its agents are responsible for any loss or damage to your property. Your property is your responsibility and if you do not assume that responsibility then any loss is your burden. By signing this Program Participant Agreement I agree that Kokopelli Group Home, LLC is not responsible for my personal property. I will be responsible to pay any packing and storage fees before I can claim my property. BINDING EFFECT The covenants and conditions contained in this agreement shall apply to and bind the heirs, legal representatives, and assigns of the parties to this agreement, and all covenants are to be construed as conditions of this agreement. GOVERNING LAW It is agreed that this agreement shall be governed by, construed, and enforced in accordance with the laws of Arizona. A FINAL NOTE This is a Recovery Program service for assistance in transitioning into society and for recovery for substance abuse, and not an agreement to occupy the facility and premises of Kokopelli Group Home, LLC. Our business is to provide a positive lifestyle program for you and other participants to become responsible, assume a positive role in society and recover from an addiction. This program includes you following our rules, regardless if you are on parole, probation or other court or legal status, and paying the applicable service fees. You must be serious to apply for participation in our program and agree to all terms and conditions. If you violate this agreement, the time is expired and the Program Participant must vacate the facility immediately or be in violation of ARS 13-1504 Criminal Trespass in the First Degree or 13-1502 Criminal Trespass in the Third Degree or both. I certify that I am ADA Handicapped Qualified, and I am fully ambulatory, and if I do become non-ambulatory I will notify Kokopelli Group Home, LLC immediately and relocate to a facility that does maintain ADA non-ambulatory complaint facilities. If you do not agree with any of the requirements that are contained within this document, or do not plan on recovery, please do not sign this agreement. * SPECIAL NOTATION: The Program Service Fees, Daily Prorating of the Service Fee and Security Deposit may require adjusting on a periodic basis. If the fees are to be adjusted, Kokopelli will give the Program Participant a minimum of 30 days written notice. In witness, each party to this agreement has caused it to be executed in Mesa, Maricopa County, Arizona on the date indicated below. Program Participant / Date Kokopelli Group Home, LLC / Date Initial location of Kokopelli Group Home, LLC: 1463 E Diamond, Mesa, AZ 85204 2210 W Cabana, Mesa, AZ 85202 2223 W Edgewood, Mesa, AZ 85202 X 552 N Temple, Mesa, AZ 85203 758 N Cholla, Mesa, AZ 85201 _______________________________ Note: The program participant may relocate from one facility location to another with the approval of any required supervisory authority. This agreement will remain in force until such time that the program participant is no longer participating in the Kokopelli Group Home, LLC Recovery Program Service. Page 8 of 8 KOKOPELLI_PROGRAM_PARTICIPANT_AGREEMENT 12/9/2008 © 2008 Kokopelli Group Home, LLC Instructions for Life Well not really, but some things you may need to do. Report to your Parole or Probation Officer (PO). Have them FAX us the “Consent to Place” form. Our FAX is (480) 275-3040, if they have not already done so. The Parole Office, for Mesa Main and Mesa Iron, is located just North of University and on the West side of Mesa Drive in a 2 story building. The address is 460 N Mesa Dr, Mesa, AZ 85210. The Mesa Iron Phone is (602) 255-3264. The Mesa Main Phone is (480) 610-1751. The Maricopa County Probation Office, for Mesa, is located at 245 N. Centennial Way, Mesa, AZ. 85201 and the main phone number is (602) 372-5300. Don’t forget to ask your PO for some bus passes. They will come in very handy. While you are reporting to your PO, take an empty suitcase or backpack with you. This is so you can go to the Salvation Army and get a food box. The Salvation Army is located just North of the Parole Office and North-East of the Mesa Probation Office. The address for the Salvation Army is 241 E 6th St, Mesa and the phone number is (480) 833-8322 Now you need to probably get your ID. The State ID is located at the AZ Department of Motor Vehicles. The closest office is probably 1840 S. Mesa Dr., Mesa. You will need some money to get the ID. If you have no money, then a charity named Paz de Cristo might be able to help. They are located at 424 W Broadway Rd, Mesa, Arizona, (480) 464-2370. That is across from the U-Haul on the N side of Broadway and Country Club. You can also get a meal in the evening there at 5:45 PM. Then just South of the AZ DMV is the United Food Bank, 358 East Javelina Avenue, Mesa. Their phone is (480) 926-4897. You can get a food box there (on Fridays from 8:00 AM to 2:00 PM-Be Early) for $15.00 (you can use your Food Stamp Card), and it is pretty good. Anything to get you started. Now you probably will need to get a Social Security Card. As a note, no employer is supposed to pay you unless you have proof of residency. You can work, but just not get paid. The closest Social Security Office to get an ID is in Phoenix. The closest address is the Downtown Phoenix office, 250 N. 7th Ave, Phoenix. When you apply they will give you a letter and mail your card. Make sure they have your SS Number printed on the letter. OK. Now you have your ID, Got some food, and Checked In with you PO. Gotta get a job. There a many places to go. Start first on the Kokopelli Website under Community Links. We have listed a lot of possible job locations, day labor and contract. Do not get discouraged. Day Labor has been tough lately, so I would suggest a couple of things. Check with your church. They will have some connections. All of the Kokopelli facilities are located close to transportation. Oh Yes Transportation. Ask your Manager for the Handicapped Bus Certificate. Fill it out and take it to the Bus Terminal located either Downtown Phoenix at Central and Van Buren (300 N. Central Avenue, Phoenix, AZ, Phone (602) 262-7433) or Downtown Tempe at 502 S College, Tempe (480) 858-2350. You will need a picture ID, the Application Certificate and $2.50. They will take your picture and give you a Handicapped ID Card. This enables you to pay half fare to ride a bus. You will want to get a month pass or a multiple day pass. Don’t forget to get an appointment for DES Food Stamps, WorkForce Connection (Jobs), and ACCESS Insurance. You will want to do that right away, like NOW! The main DES phone that I called was (602) 542-9935. Always go to the office FIRST and get an application and make an appointment. For Zip Code 85201 (Cholla) you would go to 163 N Dobson Rd, Mesa, AZ 85201. The phone number is (480) 890-7300. For Zip Code 85202 (Cabana & Edgewood) and 85204 (Diamond) you would go to 2288 W Guadalupe Rd, Gilbert, AZ 85233. The phone number is (480) 777-1168. For Zip Code 85203 (Temple) you would go to 1619 E Main St, Mesa, AZ 85203. The phone number is (480) 834-4066. For Jobs. Kokopelli has tried to gather many places that offer jobs. Thos are listed on our website http://www.kokopelli-recovery.org. Go to Community Links, then Job Searches and Placement. There is also Meetings listed, Food Boxes, Transportation and a bunch of other stuff. GOOD LUCK! PS: Please do yourself a favor right away. Go register for as many Day Labor Companies as you can. Then start hitting the companies that are close to your facility. Jobs are tough, but you can get out to work. We have put an asterisk (*) next to companies on our list that have been favorable to our program participants. Also do another thing for yourself, Go apply at Goodwill, Savers, and Deseret Industries. You might call the Mormon Church and request to talk to the Bishop. They can possibly give you a work ticket for Deseret Industries. Kokopelli will provide you with a Job Search Form, a Meeting Form, and a Daytimer Form. We expect these be completed and turned in to your manager. At the end of the week, your manager will complete an interview with you for your weekly status. This status will be maintained in our files. If you do not get a job and follow through with paying your fees, Kokopelli will place you on restrictions. These restrictions include additional chores, no visitations off or on the property, more meetings, counseling, limited TV and computer, limited use of laundry facilities, increased supervision. Be responsible and it will pay off. If you want, go out and visit other group homes. If you find one that is better, then please plan on moving there right away. We want responsible people that really do want to turn their lives around not just give us “Lip Service”. Once you do get a job, don’t just stop considering other possibilities. You should plan on working 60 hours per week to pay your bills, pay your fines, buy things for yourself, and even save a little. In today’s society 40 hours per week does not “cut it”. If you work on a job that “stops” when the boss goes on vacation, then get another job, as this one is really a hobby. Don’t quit one before you are ready to start another. If you do get as job and it does not start for a few days, then get out to somewhere to make a few bucks. Do not plan on lying around the house. That will not pay your bills. K OK OPELLI GROUPHOME Meeting Tracking Form ______________________________________ Program Participant Name Please have this form Signed by the Meeting Host. Present this form on a weekly basis to your Developmental Advocate. (Note: To document Meetings, Church, Counseling, Etc.) Date KOKOPELLI_Meeting_Documentation Meeting 07-09-2007 Meeting Host Signature © 2007 Kokopelli Group Home Kokopelli Group Home, LLC 1825 S Cholla St Mesa, AZ 85202 (480) 820-2121 Office (480) 620-2036 Mobile Steve (480) 620-2039 Mobile Dorothy (480) 275-3040 Fax Date: To Whom It May Concern: I am the director/manager of the Kokopelli Group Home, LLC located at: X 2210 W. Cabana, Mesa, AZ 85202 (480) 907-6428 758 N. Cholla, Mesa, AZ 85201 (480) 584-6583 1463 E. Diamond, Mesa, AZ 85204 (480) 219-2768 2223 W. Edgewood, Mesa, AZ 85202 (480) 219-1374 552 N Temple, Mesa, AZ 85203 (480) 474-4050 1942 S Emerson, 141 Mesa, AZ 85221 (480) 214-5303 ____________________________________________________ _____________________________________ has just moved in to the home indicated above and has not had a chance to establish a mailing. The Program Fee is $122.10 per week, including taxes and utilities. Kokopelli Group Home, LLC is registered with the City of Mesa. Each program participant must provide and prepare their own food and meals and store in their personal assigned storage area in the refrigerator and food pantry. Kokopelli Group Home does not provide nor prepare food. This is to certify that he/she is a resident. Please accept this statement as proof of residency. Sincerely, ___________________________________________ Signed by Director/Manager Kokopelli_Group_Home_Residency_Letter September 3,2008 © 2007 Kokopelli Group Home, LLC 7/20/04 REDUCED FARE APPLICATION APPLICATION FOR REDUCED FARE AUTHORIZATION CARD FOR OFFICE USE ONLY Card No. Expiration ___ - ___________ _______________ Documentation ________________________________________ ________________________________________ Today’s date TYPE OF ELIGIBILITY (Please choose one.) Senior ❏ Youth ❏ Person with Disability X ❏ APPLICANT INFORMATION (Please print.) _____________________________________________________________________________________________________ FIRST NAME INITIAL LAST NAME 552 N Temple Mesa AZ 85203 _____________________________________________________________________________________________________ ADDRESS CITY STATE ZIP CODE (480) 474-4050 _____________________________________________________________________________________________________ PHONE BIRTH DATE SIGNATURE OF APPLICANT APPLICANTS WITH DISABILITY (To be completed by a qualified health or rehabilitation professional.) DURATION OF DISABILITY: TEMPORARY X ❏ (UNTIL WHEN 1 Year ?) OR PERMANENT ❏ ! 10. ❏__________ Non-Ambulatory Disability X ICD-9 TYPE OF DISABILITY 40. ICD-9 TYPE OF DISABILITY ❏__________ Mental Disabilities 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. ❏__________ Semi-Ambulatory ❏__________ Arthritis ❏__________ Loss of Extremities ❏__________ Cerebrovascular Accident ❏__________ Respiratory ❏__________ Cardiac ❏__________ Dialysis ❏__________ Spinal Disorder ❏__________ Nerve Root Compression ❏__________ Motor 41. 42. 43. 44. 45. ❏__________ Developmental Disabilities ❏__________ Adult Mental Retardation ❏__________ Autism ❏__________ Neurological Disabilities ❏__________ Mentally Disordered Disability 50. 51. 52. 53. ❏__________ Hidden Disabilities ❏__________ Visual Disabilities ❏__________ Auditory Disabilities ❏__________ Seizure Disorder 30. 31. 32. 33. 34. ❏ Braces Additional Comments 60. X ❏__________ Other Disabilities (List) ❏ Wheelchair In Rehabilitation Recovery Program per Section 11-1-6 of the Mesa City ❏ Walker Code and H.R. Rep. No. 711, 100th Congress, 2nd Session (1998). ❏ Scooter ❏ Cane ALL INFORMATION PROVIDED IS CLASSIFIED AS CONFIDENTIAL. " CERTIFYING HEALTH OR REHABILITATION PROFESSIONAL (Please print.) Steven Collins NAME Counselor/Director 00111393 TITLE LICENSE # Kokopelli Recovery Home 480-620-2036 AGENCY OR OFFICE 1825 South Cholla St PHONE Mesa AZ 85202 ADDRESS CITY STATE ZIP CODE I certify, the the best of my knowledge, the applicant has been diagnosed with a disabling condition. SIGNATURE OF PROFESSIONAL DATE PLEASE MAKE SURE APPLICATION IS COMPLETED, SIGNED AND DATED. ADA4478/GER/0704 Kokopelli Clothing Boutique Kokopelli has established a Clothing Boutique. We have donated hundreds of pounds to Goodwill, Savers, and Deseret but they do not donate back. We purchased several high quality clothing racks and have set them up at 2210 W Cabana, Phone (480) 907-6428. The plan is to gather more clothing and offer for all Kokopelli Program Participants. There are sport coats, Golf Shirts, Shorts, and more. We need shoes, and pants. I have passed out many flyers to my neighbors soliciting more Business Casual Clothes, and they help us out. The clothing is FREE. You can make a completely voluntary donation. The only thing we ask is a small donation. This can be a dime, quarter, half-dollar, dollar or whatever. Just give to the Cabana Manager or put in the Donation Jar on the clothing rack. The donation will be accumulated for us to be able to provide Gift Cards to Participants who need clothing that we do not have (i.e., Steel Toe Shoes, Etc). If you have clothing items that are still usable, please launder and leave for me to pick up on Saturdays. Please put in a White Kitchen Bag and Mark on the outside Donation. Thanks a BUNCH! Steve & Dorothy
