Add Your Organization

How did you hear about Rise4Me™?*

Information provided in this section will be used to assist in placing your organization on the Rise4Me™ website if approved by designated reentry coordinator.

Organization Name*

Acronym

Services Offered*

(Please select all that apply)

Does your organization provide service to sex offenders?*

Yes
No
Unknown

Because you have selected ‘yes’, your organization description on the Rise4Me™ website will state that you do offer services to sex offenders.

Organization Description*

(The description entered here will be used to introduce your organization on the Rise4Me™ site)

Specialties (if any)*

(Please type all that apply)

Please select here ‘yes’ or ‘no’ if your organization is interested in learning more about participating in programs that assist incarcerated individuals and their families.

Interested in learning more?*

Yes
No

Information provided in this section is for internal purposes only if we need to contact you. This information will not be displayed on the website or shared.

Contact Information for person completing this form:

Full Name*

Position*

Email Address:*

Enter Email Address Confirm Email Address

Phone Number*

Fax Number

Information provided in this section will be used by designated reentry coordinator to review your organization and determine whether you meet the qualifications to be added to the county site. This information will not be displayed on the website or shared.

Organization Phone Number*

Website Address*

E-mail Address*

Enter Email Address Confirm Email Address

Street Address of Organization*

Street Address City State ZIP Code

Mailing Address of Organization*

Same as Street Address of Organization

Street Address Address Line 2 City State ZIP Code

Does your Organization have multiple locations?*

Yes
No

Areas Served*

(Please select all that apply)

Local County
Region
State-wide
Nationally

Counties Served*

(Please list all that apply)

Ages Served*

(Please list all that apply)

0-5
6-12
13-17
18-21
22-30
31-50
51-64
65+
All age groups

Describe your certification and provide certification numbers (if applicable)

Is your organization registered as a non-profit or with the Better Business Bureau (BBB)?*

Yes
No

Please enter your EIN or BBB rating*

Days Available*

Hours Available*

ADA Access*

Yes
No

Transportation Available*

Yes
No

Languages Spoken*

Sign Language?*

Yes
No

Video Relay Service?*

Yes
No

Application Required?*

Yes
No

Link to Request an Application*

Application Waiting Period*

Eligibility Requirements*

Fees Charged for Services*

Insurance Accepted*

Medicaid Accepted*

IMPORTANT NOTICE: *

All applications and approvals remain subject to the jurisdiction that presides over the confinement facility in the county(ies) in which you offer service and/or assistance. Rise4Me™ reserves the right to remove any listings that are found to contain invalid or outdated contact information, including inoperable web page URLs and invalid email addresses. This site is provided “as is” without warranty of any kind, either expressed or implied. You should not assume that this site is error-free or that it will be suitable for the particular purpose, which you have in mind when using it. Information on this website has been compiled from a variety of sources and are subject to change without notice. All service marks and trademarks are the property of their respective owners. By checking this box below and submitting this form, I acknowledge and agree to this approval process on behalf of the organization I represent.

I understand

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Phone

This field is for validation purposes and should be left unchanged.

Add Your Organization

Organization Application