Please initial each paragraph to indicate that you have reviewed and understand each component of
residing at Perham 180.
Please sign by typing your full legal name where indicated below:
By signing this, I verify that the statements in this application are true. I authorize the use of the
information and contacts to complete the reference checks. I understand that if I provided false
information or did not complete the application that my application may be rejected. If my
application is accepted, I understand that I will have to sign an authorization for a criminal
I authorize Productive Alternatives Perham 180 to conduct a background check as a condition of my
acceptance into Perham 180.
I hereby consent to a two-way exchange and release of information contained in my case file including
admission, treatment, and discharge planning between (current facility and staff) and Productive Alternatives Perham 180