Contact Forms - Riverside House | Coed Community Residential Reentry Facility In Miami, Florida

Main Form

Name

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

First Name *(Required)

Last Name *(Required)

Phone *(Required)

Email *(Required)

Message

Main Form

Phone

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

First Name *(Required)

Last Name *(Required)

Phone *(Required)

Email *(Required)

Message

Main Form With Dropdown

Comments

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

First Name *(Required)

Last Name *(Required)

Phone *(Required)

Email *(Required)

What Do You Need Help With? *(Required)

Message

Volunteer Application

Contact Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone(Required)

Mobile Phone(Required)

Email(Required)

Date of Birith(Required)

MM slash DD slash YYYY

Driver's License Number(Required)

Availability

During which hours are you available for volunteer assignments?(Required)

Weekday Mornings

Weekday Afternoons

Weekday Evenings

Weekend Mornings

Weekend Afternoons

Weekend Evenings

Interests

Tell us in which areas you are interested in volunteering.(Required)

Mentorship

Events

Maintenance / Cleaning

Fundraising

In-Kind Donation

Sponsor A Family

Pastoral Care

Community Service Hours

Satellite Site

Community Outreach

Special Skills or Qualifications

Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.(Required)

Previous Volunteer Experience

Summarize your previous volunteer experience.(Required)

Person to Notify in Case of Emergency

Emergency Contact Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone(Required)

Mobile Phone(Required)

Email(Required)

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

Signature of Applicant (Type Name to Sign)(Required)

Date(Required)

MM slash DD slash YYYY

Our Policy

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. Thank you for completing this application form and for your interest in volunteering with us.

Communications Consent

Please check to receive our monthly e–Blast.

Job Application

Application For Employment

Equal Opportunity Employer

Riverside House is a federal contractor and provides equal employment opportunity to all persons without regard to race, color, religion, national origin, gender, age, veteran status, disability, or any other protected classification under Federal, State, or Local Law.

By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message from Riverside House. Message frequency may vary. Message & data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information. See our Privacy Policy.

Position(s) Applied For:(Required)

Date of Application(Required)

MM slash DD slash YYYY

How did you learn about us?(Required)

Employment Agency

Friend

Relative

Walk-In

Other

Personal Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Social Security Number(Required)

Email(Required)

Employment Status & Eligibility

If you are under 18 years of age, can you provide required proof of you eligibility to work?(Required)

Yes

Have you ever applied or worked here before?(Required)

Yes

When was the date you last applied?

MM slash DD slash YYYY

Are you currently employed?(Required)

Yes

May we contact your present employer?(Required)

Yes

Are you currently on “lay-off” status and subject to recall?(Required)

Yes

Are you legally authorized to work in the United States?(Required)

Yes

On what date will you be able to start work?(Required)

MM slash DD slash YYYY

What is your availability for work?(Required)

Full-Time

Part-Time

Shift Work

Temporary

Can you travel if the job requires it?(Required)

Yes

Have you ever been convicted of a felony, misdemeanor, or any physical or other violent crime or arrested?(Required)

Yes

Note: Conviction will not necessarily disqualify an application from employment.

If yes, please explain and provide a copy of the disposition.

Education

Elementary School: Name and Address of School

High School: Name and Address of School

High School: Years Completed

High School: Diploma/Degree

Yes

Undergraduate School: Name and Address of School

Undergraduate School: Course of Study

Undergraduate School: Years Completed

Undergraduate School: Diploma/Degree

Yes

Graduate School: Name and Address of School

Graduate School: Course of Study

Graduate School: Years Completed

Graduate School: Diploma/Degree

Yes

Other (Specify below): Name and Address of School

Please Specify

Other: Course of Study

Other: Years Completed

Other: Diploma/Degree

Yes

Indicate any foreign languages you can speak, read, and write:

Language

Speak

Fluent

Good

Fair

Read

Fluent

Good

Fair

Write

Fluent

Good

Fair

Language

Speak

Fluent

Good

Fair

Read

Fluent

Good

Fair

Write

Fluent

Good

Fair

Additional Skills

Describe any specialized training, apprenticeship, skills, and extra-curricular activities.

Describe any job-related training received in the United States military.

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations, which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer 1

Employer

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone

Job Title

Supervisor

First Last

Reason For Leaving

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Starting Hourly Rate/Salary

Ending Hourly Rate/Salary

Work Performed

Employer 2

Employer

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone

Job Title

Supervisor

First Last

Reason For Leaving

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Starting Hourly Rate/Salary

Ending Hourly Rate/Salary

Work Performed

Employer 3

Employer

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone

Job Title

Supervisor

First Last

Reason For Leaving

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Starting Hourly Rate/Salary

Ending Hourly Rate/Salary

Work Performed

Employer 4

Employer

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone

Job Title

Supervisor

First Last

Reason For Leaving

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Starting Hourly Rate/Salary

Ending Hourly Rate/Salary

Work Performed

Additional Information

Other Qualifications

Summarize special job related skills and qualifications acquired from employment or other experiences.

State any additional information you feel may be helpful to us in considering your application.

References

Reference #1

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reference #2

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reference #3

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at the time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also that I am required to abide by all rules and regulations of the employer.

Signature of Applicant (Type Name to Sign)(Required)

Date(Required)

MM slash DD slash YYYY

Pre-Employment Agreement

PLEASE READ CAREFULLY

I voluntary agree to submit to a urinalysis (drug screen) as part of my application for employment. I understand that either refusal to submit to the urinalysis screen or failure to qualify to the minimum standards established by Riverside Christian Ministries, Inc. for this screen may disqualify me from further consideration for employment.

I further understand that upon commencement for employment with the company I may again be required to submit to a urinalysis screen if there is reasonable suspicion. I understand that the minimum standards set for the screen, may result in immediate suspension or discharge.

I have read in full and understand the above statements and conditions of employment.

Signature of Applicant (Type Name to Sign)(Required)

Date(Required)

MM slash DD slash YYYY

Driver License Information

State(Required)

Driver's License Number(Required)

Expiration Date(Required)

MM slash DD slash YYYY

Resume

Upload Your Resume

Max. file size: 50 MB.

DRC Application

Member's Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Home Phone

Mobile Phone

Date of Birth(Required)

MM slash DD slash YYYY

Place of Birth(Required)

Primary Language

Secondary Language

Driver's License Number(Required)

Social Security Number(Required)

Disability(Required)

Yes

Do you require any special accommodations?(Required)

Yes

If yes, please explain:

Physical Description

Height(Required)

Weight(Required)

Race(Required)

Eye Color(Required)

Hair Color(Required)

Sex(Required)

Male

Female

Body Marks / Tattoos / Piercings

Emergency Contact Information

Emergency Contact Name(Required)

First Last

Relationship(Required)

Home Phone

Mobile Phone

Address(Required)

Street Address City State ZIP Code

Medical History

Legal / Criminal Information

Current Conviction

Sentence

Referring Agency

Do you have any pending criminal or civil charges?(Required)

Yes

If yes, please explain:

Allergies

Spiritual History

Religious Affiliation(Required)

Are your active or inactive religiously?(Required)

Active

Inactive

Do you attend a local church?(Required)

Yes

If yes, name of church:

How significant is religion to your everyday life?(Required)

Occupational / Educational Information

Employer

Occupation

Hourly Wage

How long have you been employed with this company?

Work

Part-Time

Full-Time

If currently a student, what school?

Field of Study

School

Part-Time

Full-Tme

Choose last year of school completed.(Required)

Other

Any job-related certifications?

Are you interested in obtaining a certificate in another area? If yes, what kind of certificate?

Military Service (Including Branch of Service and Dates)

Reasons for Visiting the Day Reporting Center

What issues or concerns have led you to the Day Report Center?(Required)

What concerns have led you to pursue counseling?(Required)

Where is this impacting you the most? Choose all that apply:(Required)

When did this begin to be a problem for you?(Required)

Please rate the severity of your present concerns.(Required)

Mild

Moderate

Severe

What do you hope to gain from counseling?(Required)

If other people are involved in your present problem, who are they and how could they help improve the situation?

Please check services needed.

Case Management

Employment

Job Training

Government Assistance Application

Medical Referral / Dental Referral Documents

Counseling: Mental Health

Counseling: Substance Abuse

Counseling: Family

Counseling: Spiritual

Agreement and Authorization Signature

I believe that the statements I have made are true and correct. I hereby authorize Riverside House 2.0 to conduct any background checks, as needed; as well, as to contact, communicate, and verify any references or names listed on this application. I understand that any discrepancy or lack of information may result in the rejection of this application.

Signature of Applicant (Type Name to Sign)(Required)

Date(Required)

MM slash DD slash YYYY

Appointments

All appointments are made through the administrative assistant staff. Most appointments can be scheduled Monday - Friday from 10:00 AM to 5:00 PM. Appointments should be cancelled 24 hours prior to the scheduled appointment time to allow another client to be contacted to fill your appointment time. Since a specific block of time is set aside for you, we appreciate your every effort to keep your scheduled appointment. Thank you.

Initial(Required)

Podcast Guest Application

Name(Required)

First Last

Email(Required)

Phone(Required)

Social Media Handles

How did you hear about the Inside Job podcast?

What would you like to be interviewed about?(Required)

Why is this important for our listeners?

Are you happy to share your interview with your audience when it airs?

Prayer Request Form

First Name

(Not Required)

Last Name

(Not Required)

Phone

(Not Required)

Please share your prayer request. *(Required)

Recognition Awards Ceremony - Sponsorship Opportunities

Name(Required)

First Last

Company Name

Email(Required)

Phone(Required)

Sponsorship Level(Required)

Diamond Committee Sponsor $5,000

Platinum Sponsor $2,500

Gold Sponsor $1,000

Silver Sponsor $500