I want to participate in the Relapse Program which is part of the Continuous Temporary Release Program. I understand that the results of a urinalysis/breathalyzer test dated __ constitute a violation of Departmental, institutional and/or temporary release program rules and regulations. I also understand that, based upon the subject test results, I would ordinarily be served with a misbehavior report alleging a violation of the Standards of Inmate Behavior and be referred to the Temporary Release Committee for a temporary release removal proceeding. I agree, however, to waive service of a misbehavior report and any disciplinary proceeding on this issue. I further agree to participate in the Department's Relapse Program for alcohol and substance abuse treatment. I understand that I will have only one opportunity to participate in the Relapse Program. I understand that I will be transferred to a general confinement facility in order to participate in the Relapse Program and that the Relapse Program will last approximately sixty days. I realize that, in some instances, the Program will be shorter. Thereafter, if I have successfully completed the Treatment Program, I will be returned to full participation in the continuous temporary release program.

I also understand and agree that I can be removed from the Relapse Program at any time in accordance with the provisions of section 1904.1. I further understand and agree that, if I am removed from the Relapse Program, I will not be reinstated to the continuous temporary release program. I also understand, however, that I may subsequently, reapply for participation in the continuous temporary release program pursuant to applicable Department eligibility requirements.

I have read and fully understand and agree to the above terms and conditions.

Witness' signature