United States District Court for the District of New Hampshire LASER Docket Law Abiding. Sober. Employed. Responsible. ADMISSION CRITERIA I, , am seeking permission to participate in the District of New Hampshire's LASER Docket program. I understand that if I am accepted into the LASER Docket program, I must fully comply with the counseling requirements and other court orders set forth below and in the order Setting Conditions of Release. I understand that failure to comply with the terms of this agreement or the Court's orders, may result in modification and/or termination from the LASER Docket program and/or revocation of pre-trial/post-conviction release. I agree to commit no other violations of federal, state, or local law; I agree not to use drugs or alcohol; I agree to obey all instructions of the judicial officer of the U.S. District Court and the U.S. Probation Officer; I agree to provide the U.S. Probation Officer with my logins and passwords for any social network groups to which I belong; I agree to abide by the following Medical Protocol conditions: The defendant shall utilize one pharmacy and shall advise the probation officer of the name and address of the designated pharmacy. The defendant shall utilize one hospital (unless transported by emergency personnel and unable to designate the hospital to which he/she is transported) and shall advise the probation officer of the name and address of the designated hospital. The defendant shall select a primary care physician to manage his/her medical care (if needed) and shall notify the probation officer of the name, address, and phone number of the designated physician within one week of obtaining services. -1- American LegalNet, Inc. www.FormsWorkFlow.com The defendant shall notify the probation officer within twenty-four (24) hours of any modifications in his/her prescribed medication and prior to filling the modified prescription (except in an emergency). The defendant shall execute releases of infonnation allowing the probation officer to access his/her medical records maintained "by hospitals, doctors, and pharmacies. The defendant shall notify all health care providers of the specifics of hislher substance abuse addiction. I agree to submit to drug testing as directed by the judicial officer of the U.S. District Court and the probation officer and I will refrain from the use ofpoppy seeds and/ or poppy seed products. I agree to immediately enroll in the following substance abuse treatment program, and to abide by the rules and regulations ofthat program until clinically discharged: I agree to sign a release of infonnation to allow the probation officer to speak with my counselor and/or receive treatment reports on a regular basis; I understand and agree that I will be required to obtain a sponsor and attend self-help groups during my time in the LASER Docket program, in addition to any counseling sessions that I am required to attend; I understand and agree that I will be required to complete homework assignments given to me by the Court and/or the probation officer and to complete them in a timely manner; I understand that in violate any of the terms or conditions of my programming, supervision and treatment, or in fail to appear for any LASER Docket review hearing, then sanction(s) may be imposed upon me, up to and including termination from the program. I have read and acknowledge that I understand the above terms and conditions of my participation in the LASER Docket program and I agree to fully comply with those terms and conditions. Participant Date -2- American LegalNet, Inc. www.FormsWorkFlow.com I have advised my client of all of the terms and conditions of the LASER Docket program and I believe that my client fully understands those terms and conditions, and knowingly and voluntarily seeks permission to participate in the LASER Docket program. Attorney for Participant Date I recommend the above-named individual for participation in the LASER Docket program for the District of New Hampshire. Assistant United States Attorney Date I recommend the above-named individual for participation in the LASER Docket program for the District of New Hampshire. U.S. Probation Officer Date I approve the above-named individual for participation in the LASER Docket program for the District of New Hampshire. Honorable Joseph N. Laplante Chief United States District Judge District of New Hampshire Date -3- American LegalNet, Inc. www.FormsWorkFlow.com