Rise Program Application

First Name

Last Name

Birthdate

Gender Assigned at Birth

Phone Number

Email

Preferred Contact Method

Secondary Contact Method

Have you ever served in the military?

Yes

No

Which branch of the U.S. military did you serve in?

Year started

Year ended

Approximate date homelessness began

Have you received any services from Sunshine Rescue Mission before? If so, when was the last time?

Are you currently in Flagstaff?

Yes

No

Where did you stay last night?

How did you hear about the RISE Program?

Have you previously participated in a residential program lasting longer than 90 days?

Yes

No