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Home » About Us » A.R.R.I.V.E. Pre-Registration Form

A.R.R.I.V.E. Pre-Registration Form
   
Date  
Cycle  
Day Classes Evening Classes  
Social Security  
   

Please fill out all information requested below. ALL INFORMATION PROVIDED IS KEPT STRICTLY CONFIDENTIAL! If you have any difficulty filling out this registration form someone will be available to assist you. Thank you for choosing the ARRIVE Training Program.
First Name Last Name
Street Address Borough/Country
Zip Code Phone Number
Date of Birth      
Age  
Gender M   F Transgender - Identify as M   F
Do you have a chronic illness (i.e. HIV, Hepatitis C) Yes   No
If Yes, please specify:
Co-Morbid Conditions:
(These would be other chronic conditions or illnesses not specified above.)
Substance Use   MICA (Mental Illness w/ Chemical Addiction)   SPMI (Serious and Persistent Mental Illness)  
TB (Tuberculosis)   MR/DD (Mental Retardation/Developmentally Disabled)   Physically Challenged  
Pregnant & HIV+   Asthma   Epilepsy
 
Ethnicity:
Race:
Language: Primary: Secondary:
Housing:
Income of household:
HIV Exposure: What may have put you at risk of getting infected with HIV.
HIV Status:
Have you ever attended ARRIVE in the past? Yes   No
If you answered Yes, what cycle?
 
If refered by a Program of Agency.
Agency Name:
Type of Program Agency:
Address:
Contact/Person:
City/State/Zip:
Phone:

What benefits are you receiving? (Please select all that apply):
PA   ADAP   HASA   SSI   SSD   Medicaid   Medicare   Private   VA   None  
 
Have you ever been arrested? Yes   No
Have you ever been incarcerated? Yes   No
Are you currently on parole? Yes   No
Were you ever on parole? Yes   No
Were you ever on probation? Yes   No
Do you have a history of substance abuse? Yes   No
1st drug of choice: Was it an IV drug? Yes   No
2nd drug of choice: Was it an IV drug? Yes   No
Are you employed in the HIV/Substance Abuse Field? Yes   No
If so, where? : Title:
Highest grade completed:
How did you find out about ARRIVE?
Other, please specify:
Why are you interested in attending ARRIVE?
Emergency Contact: This would be the person you indicate to us as the person to call in case of emergency. This information will be strictly used for emergency purposes only.
Name:
Relationship:
Phone:


exponents

151 West 26th Street, 3rd Floor
New York, NY 10001
Tel: (212) 243-3434
Fax: (212) 243-3586

Directions:

#1 to 23rd or 28th Streets and walk to 26th Street, 6th & 7th Avenues

#2 or #3 to 42nd Street Change to #1 to 23rd or 28th Streets

A, C, or E to 23rd & 8th Avenue Walk East to 26th between 6th & 7th Avenues

F, V to 23rd & 6th Avenue between 6th & 7th Avenues

N, R to 23rd or 28th Street & Broadway walk west to 26th between 6th & 7th Ave.

 
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