Join the RISE Movement: Enroll!
Thank you for your interest in the RISE Youth Program. Please complete each section of the form and submit it. A member of our team will follow up with you to gather any additional information needed about your youth.
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
Youths Full Name (Including Middle Name if any)
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Please upload Birth Certificate to confirm Date of Birth:
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Cancel
of
Sex of Youth:
*
Male
Female
Other
Race of Youth:
*
Black
White
Asian
Pacific Islander
Asian
Hispanic
Other
Full Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name & Grade Level:
*
Any Behavioral or Learning Challenges? (Yes/No, if yes explain)
*
Is your child currently involved in any open or ongoing legal or criminal matters?
*
What are your primary goals for your child in this program? (Open-ended response)
*
Does your child have any allergies that we should be aware of?:
*
Is there anything that would help us better understand or support your child during their time in the RISE program?:
*
Legal Parent / Guardian Contact Name:
*
First Name
Last Name
Please upload a copy of your Driver License or State ID card:
*
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Cancel
of
Relationship to Child:
*
Does Youth Reside with You?:
*
Yes
No
Foster Care
Emergency Phone Number:
*
-
Area Code
Phone Number
Email:
example@example.com
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.
Please confirm your commitment to your child arriving on time (10:00 AM) for Saturday programming.
*
Yes, I will ensure that my child arrives promptly at 10:00 AM
I or my desginee will ensure that my child arrives promptly at 10:00 AM
I may have challenges with getting my child to Saturday programming
Other
Is there anything that would help us better understand or support your child during their time in the RISE program?
*
Signature
*
Submit Enrollment Application
Should be Empty: