Community Assistance Application – Ruff Ryders to the Rescue

Community Assistance *

See Assistance Descriptions

Support A Cause

Hobby Programs

Date *

Name *

First

Middle

Last

Gender *

Male
Female

Address *

Address Line 1

City

State

Apartment/Unit #

Zipcode *

Phone *

OK to Send Text: *

Yes
No

Email *

Age Range *

Health Issues/Physical Limitations *

Yes
No

Allergies/Medical Conditions

RR Lifestyles Chapter

Ryder/Alias Name

Email

RR Lifestyles Account Standings

Current
Behind

Chapter Name

Chapter President

Military Service

Service Branch

Date of Entry

Date of Exit

Rank at Discharge

Type of Discharge

If Other Than Honorable, Explain:

Additional Contact

First Contact

First

Last

Phone

Email

Second Contact

First

Last

Phone

Email

Disclaimer and Signature

I certify that the information contained in this application is true and complete to the best of my knowledge. I understand that false or misleading information may be result in cancellation of support.

Signature *

Date / Time *