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Community Assistance Application
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Community Assistance
*
Choice 4
Domestic Violence
Drug Rehabilitation
Employment
Food Drive
Gang Intervention
Health
Home & Shelter
Safe House
Senior Assisted Living
See
Assistance Descriptions
Support A Cause
Choice 3
Rescue Business Loan
Rescue Security Training
Youth Mentorship
City Street Cleaning
Hobby Programs
Choice 3
Lifestyle Membership
Ruff Ryders Indy Music
Young Ryders Membership
Date
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Name
*
First
Middle
Last
Gender
*
Male
Female
Address
*
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Apartment/Unit #
Zipcode
*
Phone
*
OK to Send Text:
*
Yes
No
Email
*
Age Range
*
Choice 10
21 to 25
26 to 30
31 to 35
36 to 40
40 to 50
50 to 60
60 to 70
70 to 80
81 and up
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
MM
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1928
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1926
1925
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1923
1922
1921
1920
Date of Exit
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YYYY
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2015
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1924
1923
1922
1921
1920
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.
Date / Time
*
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YYYY
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1993
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1991
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1989
1988
1987
1986
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1978
1977
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1974
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Phone
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