HOW TO APPLY TO OUR PROGRAM 

PLEASE PRINT OUT THE FOLLOWING FORMS AND SUBMIT  FOR APPLICATION INTO OUR PROGRAM 

RELEASE OF INFORMATION IS REQUIRED TO BE SIGNED BY CLIENT AS ENTRY INTO CONNEXION POINT INC. 

WE OFFER A PAYMENT PROGRAM WITH THE PAYMENT AGREEMENT TO BE COMPLETED AND SIGNED ON ENTRY INTO THE PROGRAM.

COMPLETE THIS FORM 

PLEASE COMPLETE THIS FORM SO WE HAVE A BETTER UNDERSTANDING OF ANY MEDICAL CONDITIONS.