UARCO Online Application Form Application Form Step 1 of 3 - Section I 33% Member New Member Existing Member Renewal Reinstate Membership Section I: Recovery Community Organization InformationName of organization: Address: City: State: ZIP: Recovery community organization is a… Corporation Nonprofit corporation Limited Liability Company (LLC) Not for profit organization Unincorporated entity Please provide a square foot estimate of the RCOMission:Please provide your mission statement:Vision:Please provide your vision statement:Where does RCO operate out of Office-style building Residential building or house Church Do you have general liability insurance? Yes No Section II: Member informationMember/applicant name: Member/Applicant affiliation with organization Website Number of paid staff membersDoes the applicant own or operate a licensed alcohol & drug or mental health program or facility? Yes No Does your organization accept health insurance? yes no Does your organization receive health insurance reimbursements? yes no Does your organization allow multiple pathways to recovery? yes no Does your organization provide a peer-to-peer recovery-related group schedule throughout the day? yes no Does your organization provide linkage to recovery services? yes no Is your organization open to the general public? yes no Do you have a written code of ethics? yes no Do you maintain an accounting system that fully documents all financial transactions such as fees, payments, and deposits? yes no Do you collect and report accurate process and outcome data for continuous quality improvement? yes no Do you keep records secure with access limited to authorized staff only? yes no Do you have a grievance policy and procedure for participants, staff, community stakeholders, and/or the general public? yes no Do you abide by all local building and fire safety codes? yes no Have you read and agree to fully comply with VARCO Standards as set by VARCO? yes no Section III: Contact InformationPrincipal business contact for this member organization:Name: Position title or duties: Principal contact phone:Principal contact email: Section IV: Applicant affidavit and signatureI hereby attest that the above information is true and complete, and that I am authorized toexecute this application on behalf of the applicant. Applicant hereby requests membership in theVirginia Association of Recovery Residences.Name Date MM slash DD slash YYYY I have fully read* Further, I have fully read, understand, and agree to abide by the VARR Code of Ethics. NameThis field is for validation purposes and should be left unchanged. Δ
