CORE Member Application Form

This form may take more than 30 minutes to complete and must be completed in one sitting. Set enough time aside before beginning the form.

Please fill out the Member/Ally Application below. Following the form completion, you will receive a confirmation email with the next steps you must take.

Current Start
Previous Education
Referrals
About you
Mental Health History
Drug and alcohol use history
Eating Disorder History
Complete

Indicates required field

CORE Member/Ally Checklist

I have made a personal commitment to maintaining recovery

I actively participate in a program or practices that support maintaining my recovery

I am interested in participating in a recovery-focused community, sharing support and being of service to others

I am willing to follow Core Member Guidelines and uphold the values of the CUCRC community (see attachment)

I agree to attend at least one weekly meeting at the CUCRC (Recovery Talks, Community, etc.) and monthly social

First Name

Middle Name

Last Name

Preferred Name

Pronouns

Birth Date

Recovery/Sobriety Date (if applicable)

Phone Number

Current Mailing Address

Apartment/Unit Number

City

State

Zip Code

Email Address

Major/Course of Study

Student ID Number

Emergency Contact

Relationship

Emergency Contact Phone Number

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CORE Member Application Form