R.I.S.E. Initiative – Application

Preview mode

Published

Copy responder link

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

R.I.S.E. Initiative – Application

Welcome to the R.I.S.E. Initiative! Please answer the following questions below so we can learn a little more about you and best know how to assist you.

The R.I.S.E. Initiative does not discriminate on the basis of age, race, ethnicity, gender, sexual orientation, disability or religion. All responses will be kept confidential.

Name *

Address (street address, city, state, zip code) *

Home Phone

Cell Phone *

Age *

Highest Level of Education Completed *

Middle school

Some high school

High school diploma/GED

Associate's degree (2-year)

Bachelor's degree (4-year)

Advanced degree

Gender *

Female

Male

Transgender

Non-Binary/ third gender

Prefer to self describe

I don't know/Not sure

Prefer not to answer

Race *

African American/Black

American Indian or Alaskan Native

Asian

Bi-Racial/Multi-Ethnic

Caucasian/White

Latino/Hispanic

Native Hawaiian or Other Pacific Islander

I don't know/Not sure

Prefer to self describe

Prefer not to answer

Other:

Ethnicity *

Latino/Hispanic

Non-Latino/Non-Hispanic

I don't know/Not sure

Prefer not to answer

What is your current housing situation? *

Rent/Lease

Homeowner

Living with a friend or relative

Shelter/Emergency housing

Subsidized housing (Section 8, Public Housing, etc.)

Residential facility (halfway house, intensive program, etc.)

Couch surfing (stay temporarily in a series of other people's homes)

Uncertain of where I will stay each night

Other:

Have you been diagnosed by a doctor with any of the following? (check all that apply): *

*You have the opportunity to discuss your specific situation with a staff person.

Chronic or ongoing health condition (i.e. heart or lung disease, diabetes, asthma, etc.)

Physical disability

Developmental disability (severe chronic disability that limits ability to function independently)

Mental health condition (depression, anxiety, PTSD, etc.)

Substance abuse

I have not been diagnosed with any of the above by a doctor

Prefer not to answer

Required

If you checked off any of the above, are you receiving treatment?

*You have the opportunity to discuss your specific situation with a staff person.

Yes

Clear selection

If you are receiving treatment, please provide more information below.

*You have the opportunity to discuss your specific situation with a staff person.

Is English your first language? *

Yes

If no, what is your primary language?

If English is not your first language, please rate your level of English proficiency.

Low

High

Clear selection

Have you completed any training or certification programs? *

Yes

Have you ever been employed before? *

Yes

Are you currently working? *

Yes

If yes, who is your employer?

Do you have access to the internet? *

Yes

Do you have a laptop or tablet? *

Yes

How familiar are you in using digital video conferencing software? (For example, Zoom, Google Hangouts, etc.) * *

Not Familiar (I have never used video conference software)

Somewhat Familiar (I have used video conference software more than once)

Very Familiar (I use video conference software often)

Do you have any previously scheduled activities that will prevent you from attending the R.I.S.E. Initiative on a regular basis (e.g. work, school, appointments)? *

R.I.S.E. Initiative activities usually occur Monday and Thursday between 11:00 AM and 12:30 PM.

Yes

If yes, please provide the day(s) and time(s) of those previously scheduled activities below :

How can the R.I.S.E. Initiative best assist you? *

(Check all that apply)

Employment Assistance (e.g. getting a job)

Education Assistance (e.g. getting my GED, enrolling in school)

Connection to Job Training/Apprentice Program

Housing Assistance (e.g. obtaining housing)

Other:

Required

How did you hear about the R.I.S.E. Initiative? *

(Check all that apply)

Friend/Family

Social media (e.g. Facebook, Instagram, Twitter, etc.)

Referral through Episcopal Community Services

Other:

Required

In five sentences or more, tell us about some goals you would like to work on while participating in the R.I.S.E Initiative. *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms