Join the RISE Movement: Enroll, Donate, or Mentor!
Thank you for your interest in the RISE Youth Program. Whether you're a parent looking to enroll your child, a community member interested in mentoring, or someone who wants to support our mission financially, this form will guide you through the process.
Your Name:
*
Prefix
First Name
Last Name
Email:
*
example@example.com
Phone Number:
*
-
Area Code
Phone Number
Please selection one:
Please Select
I want to enroll my child in the RISE Program
I want to become a mentor for RISE
I want to donate to support the program
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Section 1: Enrollment Application
Childs Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
School Name & Grade Level:
*
Any Behaviral or Learning Challenges? (Yes/No, if yes explain)
*
What are your primary goals for your child in this program? (Open-ended response)
Emergency Contact Information:
*
First Name
Last Name
Relationship to Child:
*
Emergency Phone Number
*
-
Area Code
Phone Number
Permissions & Agreements (Checkboxes)
*
I give permission for my child to participate in all RISE activities.
I agree to allow my child to be photographed for program purposes.
I understand that RISE is not responsible for personal belongings.
Signature
*
Submit Enrollment Application
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Section 2: Mentorship Application
Full Name:
*
Email:
*
Your Phone:
*
-
Area Code
Phone Number
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Background & Experience
Have you mentored youth before?
*
Yes
No
Why do you want to become a mentor for RISE? (Open-ended response)
*
What skills or experiences do you bring that would benefit the youth? (Open-ended response)
*
What is your Availability to mentor?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Best Time of Day to mentor?
*
Morning
Afternoon
Evening
Preferred Mentoring Format...
*
In person
Virtual
Both
Background Check Authorization (I consent to a background check as part of the mentorship process.)
*
Yes
No
Signature
*
Submit Mentorship Application
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Section 3: Donation Form
Full Name:
*
Email:
*
example@example.com
Phone Number:
*
-
Area Code
Phone Number
Business/Organization (if applicable):
*
Donation Amount:
*
$25
$50
$100
$250
Other
Payment Method:
*
Credit/Debit Card (Please call (727) 386-1016
Check (Please mail checks to PO Box 35043 St. Petersburg, FL 33705)
Would you like to be recognized as a donor?
*
Yes
No
If yes, how would you like your name displayed?
Submit Donation Form
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