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REVEL Applicationrevelinlifedev2025-02-03T23:41:17+00:00

REVEL Application Form

Which program are you interested in

Gear Up (18+ Monday-Friday 9am-3pm)

Rev Up Employment Program (13+)

Individualized Supports (13+)

Lounge (13+ evenings and weekends)

Teen Summer Program (13-17)

Outdoor Adventures Camps (13+)

Transitions (18-21)

Mental Health Services

Client Name(Required)

First Last

Client Date of Birth(Required)

Month

Day

Year

Your Name(Required)

First Last

(Person filling out the form, if not client)

Relationship to the client

What county do you live in?

How did you hear about us?

Please describe the problem for which you are seeking help

Funding Source

DD Waiver (Gear Up, Lounge, Supports, Employment, Mental Health)

SLS Waiver (Gear Up, Lounge, Supports, Employment, Mental Health, Outdoor)

State SLS (Gear Up, Lounge, Supports, Employment, Mental Health)

CES Waiver (Lounge, Teen, Outdoor)

ML Waiver (Gear Up, Lounge, Supports, Employment, Mental Health, Outdoor)

DVR (Employment, Supports)

Private Pay (All Programs)

School District (Transitions, Supports, Employment, Mental Health)

How Can We Reach You?

Preferred Method of Contact

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Best Time to Call You

Any additional comments or things we should know?(Required)

CAPTCHA

Phone

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

3501 Blake Street #250
Denver, CO 80205

720-502-4927

INFO@REVELINLIFE.ORG

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