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RISE Registration and Referral Form

Please complete the form below and click "Submit Form" to submit the information. When the registration is received, confirmation and directions will be sent to the DORS counselor and consumer.

If you require a special accommodation or have other special needs, please request that information in the form below 10 working days before the first class meeting.

DORS Counselor Info





Applicant Info




MM/DD/YYYY

Gender: *

RISE Course:



MM/DD/YYYY


RISE Option Requested:
Select One: *





Disability Information:
Select all that apply: *






Ethnic Information:
Select One: *






Benefits Information:
Select One: *



Veterans Information:
Please select one *


Special Accommodations Request: Special accommodations will be provided upon request (with 10 business days notice). Please specify below:

Select All that Apply: