Click here to participate
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We are on a mission to help many. None of your answers will be the cause of denial. Please understand we get many requests. We hope this gathering of statistical data will give us important insight to help many more in the future. Please be honest in all your answers. Contact information you share with us is confidential and will not be sold or shared. If you are awarded a scholarship, we would like to hear back from you to see if you stayed sober, and if you believe a scholarship from CLEAN Cause helped you. Email any updates you would like to share to hello@cleancause.com.
**Please DO NOT complete multiple applications within the same month, or contact us asking the status of your application. If we are able to grant you a scholarship, we will be in touch with you.**
We are grateful for your participation and wish you all the best. Keep Rockin'!!
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| What is your first name and last initial? | |
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| What State, City were you in when you last used drugs or alcohol? (please give the state then the city). | |
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| | Would you like help finding a Temporary Sponsor? | |
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| | Temporary Sponsor Preference (they must be the same sex as yourself): | |
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| What is your highest level of education? | |
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| Are you currently employed | |
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| How many children do you have? | |
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| What is your SOBRIETY date? | |
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| How many times have you been sober? | |
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| In the past what was the longest consecutive sobriety you have had? | |
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| We know it's complicated but what were a few reasons you relapsed? | |
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| What main substance brought you to getting sober? | |
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| Have you lived in Sober Living before? | |
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| If you previously lived in Sober living what was the longest period of time? | |
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| Do you have a felony drug charge due to your addiction? | |
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| Why do you think sober living will help you now? | |
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| How will a Scholarship from CLEAN Cause help you to get back on your feet? | |
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| What was the event that caused you to get sober this time? | |
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| Have you been institutionalized due to Alcohol or Drugs? | |
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| Have you ever been homeless due to your drug/alcohol addiction? | |
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| What are you doing to stay sober? Be honest! This will not cause you to miss out on a scholarship. | |
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| Are you coming out of a drug rehabilitation? | |
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| | If Yes, which treatment center? | |
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| Why do you think you should be awarded a scholarship? | |
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| Do you know what house you are moving into? | |
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| If Yes, Please give the name and address of the sober house? | |
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| Have you ever attempted suicide? | |
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| If you previously lived in sober living how did it help you? | |
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| How long do you plan on staying in sober living? | |
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| What is the most amazing thing that has happened to you in your sobriety? We want to smile with you. | |
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| | Anything else you would like to tell us? | |
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| May we contact you in the future to see if you have stayed sober? Just in case events change, who can we contact to ask how you are...sober or not sober? Please give a first name, relation, phone number and email address. | |
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| | By submitting this form, you are giving permission to Clean Cause, Inc. to use your answers in gathering statistical data for future analysis. No name or contact info will be sold or shared. Do you agree? | |
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