Apply Here

I am Applying for
- FLY Case Management Program
- RISE Residential Program
Please note that there is a waitlist for our Residential Program. Do you currently have safe and stable housing? How long do you expect that to last?
Personal Name*
Last Name*
Gender Identity*
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birth Date*
MM slash DD slash YYYY
Current Age*
Please enter a number from 17 to 24.
Phone*
Email*
Enter Email Confirm Email
DCP&P / Case Worker / Name of Person who referred you
First Last
Email DCP&P / Case Worker / Name of Person who referred you
Phone of DCP&P / Case Worker / Name of Person who referred you
I want to join Roots & Wings because*
During my time with Roots & Wings I would like to achieve*
(for example, education goals, employment goals, etc.)
What are some activities, hobbies, sports you enjoy?*
Are you currently employed?*
- Yes
- No
If so, where?*
Are you currently in school?*
- Yes
- No
Where are you currently enrolled?*
What is your current living situation?*
ie. living with alone, with friends, in a group home, etc.
By signing here, I am authorizing a Roots & Wings member to contact you via the phone and/or the address provided above.*
First Last
Today's Date*
MM slash DD slash YYYY