Application Form - Rise Above Be Relentless Foundation

Intake Application for Survivor Support

Section 1: Applicant Information

Full Name:

Date of Birth:

Address:

Phone Number:

Email:

Preferred Contact Method:

PhoneEmailOther

If Other, please specify:

Section 2: Household Details

Number of children/dependents:

Ages of children:

Are you currently residing in a shelter?

YesNo

Name of the shelter (only if Yes selected):

Emergency Contact Name:

Emergency Contact Phone:

Section 3: Eligibility Verification

Please check all applicable:

Survivor of Domestic Violence or Sexual TraumaMilitary/Veteran FamilyReferral Letter with Agency/Advocate Name

Supporting documents (upload):

Section 4: Areas of Need

Utility PaymentsChildcare SubsidyLegal AssistanceEmergency needs (food, supplies, transportation)Funding for Legal AidOther

Utility bill type (3-6 month):

Childcare provider details (3-6 month):

Legal assistance description:

Emergency needs details:

Funding for Legal Aid description:

Other needs (please specify):

Section 5: Statement of Need

Section 6: Consent and Signature

I certify that the information provided is true and complete. I authorize the Rise Above Be Relentless Foundation to verify information for eligibility purposes. All information will remain confidential.

Signature:

Date:

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