Devoted to advancing the lives of others

Intake Form – for Data Entry

Client Intake Form (#22)

OFFICE USE ONLY

 

CLIENT DOCUMENTATION

 

CLIENT INFORMATION

 

Household Information

List everyone that lives in your home.


MILITARY STATUS

Please choose one


PLEASE SELECT YOUR RACIAL CATEGORY

Please choose one


PLEASE SELECT YOUR ETHNIC CATEGORY

Please choose one


ARE YOU RECEIVING ANY ASSISTANCE?

Please select ALL boxes that apply to ANY ASSISTANCE your family is receiving.


EMPLOYMENT STATUS


TOTAL ANNUAL HOUSEHOLD INCOME


CLIENT ACKNOWLEDGEMENT

I certify that I am a member of the household listed above, 18 years of age or older, and certify that all information regarding my household is true to the best of my knowledge.  


NOTE: Your answers on this form are important to help determine how to best serve you, and to obtain funding to support our programs.

All applicants MUST sign this form digitally.

IMPORTANT - Another Required Form

After you submit this form, the PRODUCT LIST will become available for you to complete. 

The Product List tells us what cleaning products for personal care, baby care, or your home you are in need of.

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