RISE Application First Name Last Name Gender Identity Female Male Non-Binary Transgender-Male Transgender-Female Do you identify as part of the LGBTQIA+ community? yes no Date of Birth Current Age Phone Number Email Address Preferred Method of Communication What is your current living situation? Do you currently have stable housing? Yes No How long do you expect your current housing to last and why do you have to leave your housing (for example: aging out of an independent living program)? How did you hear about the Roots & Wings RISE Program? Current Address Address Line 2 City State Zip Code Did you ever or do you currently have an open case with the Division of Child Protection & Permanency (also referred to as DCP&P, DCF, or DYFS)? If you currently have an open case, what is worker’s name and phone number? Why do you want to join the Roots & Wings RISE Program? If you were accepted into RISE Program, what would you like to work on and/or achieve? Where do you see yourself in five years? What are some activities, hobbies, sports you enjoy? Are you currently employed? Yes No If employed, where? Are you currently in school? Yes No If in school, where? How do you get around? (i.e. Uber/Lyft, own car, public transportation) Have you been in an independent living program? If so, how was your experience? By clicking here, I am authorizing a Roots & Wings member to contact you via phone and/or the email address provided above. Send
