RISE Scholarship Application

RISE Scholarship Application

Scholarship application for RISE Community Services. Please complete the form and submit the required documentation where indicated.
At RISE Community Services, we believe that every person deserves the opportunity to live their best life — a life filled with purpose, connection, and possibility. The RISE Scholarship was created to help individuals and families overcome barriers and move confidently toward their dreams. Whether you’re seeking support to develop new skills, need adaptive equipment or therapies, explore employment opportunities, access transportation, or enhance your daily living — this scholarship is here to help you take that next step forward. We understand that life can bring unexpected challenges, but it can also bring incredible moments of growth. The RISE Scholarship exists to remind you that your journey matters — and that you are not alone. Our community stands beside you, ready to help build pathways to empower you to live, work, and engage. Once your application is received, RISE will contact you, or your support team, to obtain any additional information needed for your request. Once your application has been reviewed by The RISE Funding Allocation Committee, a member from RISE staff will contact you to discuss the next steps. Please complete all applicable fields. Attach documentation where requested. Send completed applications to info@watchusrise.org. For questions, call 660-747-7990 and ask for the Community Resource Specialist.
Submission Details
Emergency Request
Submission Date

MonthDayYear
Date
Representative or Advocate Name
Representative/Advocate Email
example@example.com
Representative/Advocate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Applicant Information
Applicant Name
Age
County
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Diagnosis
Date of Onset

MonthDayYear
Date
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Applicant Email
example@example.com
Diagnosis Documentation

Cancelof
Alternate Contact (if applicable)
Contact Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Request Details
Service/Item Requested
Amount of Request ($)
Product Pictures or Service Details

Cancelof
Justification for Services / How will this improve Quality of Life?
Insurance Coverage
Does your current insurance provider cover this need?
Have you been denied coverage for this need?
If denied, please explain
RISE Services Requested
Sliding Scale Discount Program (RISE Services Only; excludes transportation) RISE offers a Sliding Fee Discount Program to meet the needs of those seeking services with no other funding sources. The Federal Poverty Guidelines (http://aspe.hhs.gov/poverty) are used to update eligibility annually. http://aspe.hhs.gov/poverty
RISE Services Requested

Other
If you selected “Other,” please specify.
Transportation Days Requested (If Needed)
Sliding Scale Discount Program / Financial Information
Family Size
Monthly Gross Income ($)
Income Documentation (3 months of statements)

Cancelof
Income Notes
Funding Resources & Outcomes
Funding resources or support tried or used
Outcome if funding is not available. If unsure, please write "N/A".
Are you requesting that RISE directly fund/pay for services or items? Yes ☐ No ☐ If approved, a Direct Payment Request Form will be sent.

Other
Awareness & Permissions
How did you hear about the RISE Scholarship?

Other
May we contact you to share your story?
Marketing Permission
Application Signatures: Must be signed by an individual or guardian requesting the funds.
Signature & Authorization
Signature of Individual/Guardian
Signature Date

MonthDayYear
Date
Additional Signature
Verbal permission (individual) - Date

MonthDayYear
Date
Verbal permission (individual) - Time

Hour Minutes

AM/PM Option
Verbal permission (guardian) - Date

MonthDayYear
Date
Verbal permission (guardian) - Time

Hour Minutes

AM/PM Option
Funding Parameters (Summary)

• Funding available only for residents of Johnson and Henry County, Missouri.

• Applications considered per fiscal year (Jan–Dec). Reapply annually for continued funding.

• Funding is not awarded for legal fees, deductibles, debts, utilities, rent, appliances, or prescriptions.

• Home modifications: RISE is not responsible for owner coordination, permits, supervision, or completion.

• All approvals contingent on available funds and RISE discretion; funding may be withdrawn.

• If service availability is limited, RISE can connect you with other providers.

• If requesting direct payment, an additional Direct Payment Request Form will be sent.

• Respite and Personal Care not provided by a provider are reimbursement only.
Disclaimer: RISE Community Services cannot guarantee that funding will be available. Applications will be considered and accepted or denied at the sole discretion of RISE Community Services based upon the projected availability of funds in any given year and upon criteria established by RISE leadership. RISE will make all funding decisions without regard to age, ancestry, color, disability, ethnicity, gender, gender identity or expression, genetic information, HIV/AIDS status, military status, national origin, pregnancy, race, religion, sex, sexual orientation, or veteran status, or any other bases under the law. Applicants who are denied shall have no right of appeal or legal recourse against RISE or its members. RISE does not guarantee that any applicant will receive an explanation or reasoning as to why funding is denied.

Once your application is received, RISE will contact you, or your support team, to obtain any additional information needed for your request. Once your application has been reviewed by The RISE Funding Allocation Committee, a member from RISE staff will contact you to discuss the next steps.

RISE Scholarship Application

Submission Details

Applicant Information

Alternate Contact (if applicable)

Request Details

Insurance Coverage

RISE Services Requested

Sliding Scale Discount Program / Financial Information

Funding Resources & Outcomes

Awareness & Permissions

Signature & Authorization

FOR OFFICE USE ONLY