PARTICIPANT REQUEST FORM

Please complete information below prior to submitting

Submission of this form does not guarantee approval of the request. Per handbook, requests must be submitted 7 days in advance of event. Please be advised that approval of the request is contingent upon no sanctions, treatment responses, or administrative responses being given between approval and the date of the request. Additionally, all requests must be submitted during business hours.

* Indicates required field

Name *

First

Last

Phone Number *

Case Manager *

Email *

Date(s) requested *

Type of Request *

Reason for Request *

For Employment include: (1) Name of Employer, (2) Address, (3) Supervisor name, (4) Work phone number, (5) Anticipated work schedule, (6) Hours per week, (7) Wage information (rate per hour/week), (8) How will pay be received (check or cash), (9) W-2 or 1099 Employee

Details of Request *

Supporting documentation *

Max file size: 20MB

Submit

Participant Request Online

Please complete information below prior to submitting