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RALLY project intake form
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Email *
Last name *
First name *
Maiden name
Last address *
Last address contact info *
Dates of residence *
Reason for leaving *
Are you or a member of your immediate family currently serving in the Military? *
Are you or a member of your immediate family a veteran? *
Do you have a DD214 for this service *
Are you or a member of your immediate family currently serving as a First Responder *
Did you or a member of your immediate family formally serve as a First Responder *
If so, where and when?
Who is your emergency contact *
Please provide info on anyone in your household
Relationship to you
Please explain your need *
Are you currently employed? *
Current employer
Employer contact info
If not employed, briefly explain?
Please provide requested information on all the sources of income that are received by ALL MEMBERS of your household:
What is the total amount of income in your household received from assistance. Please list total from list below.
Child support
Social security
Worker Comp.
VA benefits
Are you or anyone in your household on or ever been on a sex offender register or OFAC/terrorist database records ?
Do you require a wheelchair-friendly home? *
Confidentiality of release policy:  Please read the following information carefully, before checking box below.  Please let us know if you have  any questions. I give my permission to RALLY project  to share pertinent confidential information given on my application and in my case file, give authority, as deemed necessary, with churches, organizations, utility companies, pharmacies, state and/or federal agencies, and/or medical care institutions, in order for RALLY project to provide assistance that I request.  This release of information will remain in effect unless terminated in writing by me.  All the information given is true and correct to the best of my knowledge.  At any time, I can revoke this consent to share information.   *
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