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Good Samaritan Community Services
FAMILY HOUSEHOLD REGISTRATION FORM
Date
*
-
Month
-
Day
Year
Date
HEAD OF HOUSEHOLD/ADULT PARTICIPANT
Please provide information on the primary caregiver or adult applying for services.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
Prefer not to Answer
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
*If San Antonio, list City Council District:
Email
example@example.com
Home Phone
*
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Marital Status
*
Single
Married
Widowed
Separated
Divorced
Not Married, living with partner
Disability Status
*
Yes
No
Not Assessed
Race
*
Caucasian (white)
Black/African American
Asian
American Indian
Hawaiian/Pacific Islander
Mixed Race
Unable to determine
Prefer not to answer
Other
Hispanic Origin
*
Hispanic
Non-Hispanic
Unable to determine
Employment
*
Employed Full-Time
Employed Part-Time
Not Employed
Employer and Title
How did you hear about our services?
*
Currently receiving services
Friend/Family
Website
Texas Youth Runaway hotline
Child Protective Services
Received Services Before
Flyer/Brochure
211/other resource directory
School/Daycare provider
Juvenile Justice System
My Child
Community Fair
Clergy/Church
Healthcare Provider
Walk-in
Social Media
Family Connections
Law ENforcement
Other
HOUSEHOLD DEMOGRAPHIC INFORMATION
Living Situation (check all that apply)
*
Two Parent (Married)
Two Parent (Unmarried)
Single Parent Home
Legal Guardian
Teen Parent
Grandparent Caregiver
Forster Parent
Adopted Child
Multi-generational
Living in Public Housing
Homeless
Living in Shelter
Live with parents/family
Temporary living arrangement
Renting Home
Own Home
Number of family members in household (other than yourself)
*
Preferred Language in Household
*
English
Spanish
Vietnamese
Chinese
Other
Highest Grade Completed by Primary Caregiver
*
K-12
HS Diploma
GED
Some College
Technical Degree
Associate Degree
Bachelor Degree
Post Graduate Degree
Highest Grade Completed by Secondary Caregiver
K-12
HS Diploma
GED
Some College
Technical Degree
Associate Degree
Bachelor Degree
Post Graduate Degree
Health Insurance for Household Members
*
Employer Insurance
VA Insurance
Medicaid
Medicare
CHIP
Affordable Care Act
Carelink
No Insurance
Other
Military Status
*
Active Duty
Active Reserve
Inactive Reserve
National Guard
Civilian/Military Contractor
Retired
Veteran
DOD
No Military
Discharged-Dishonarable
Annual Household Income
*
Less than $5,000
$5,000 - $9,999
$10,000 - $14,999
$15,000 - $24,999
$25,000 - $34,999
$35,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 or above
Sources of Household Income (check all that reply)
*
Not Working
Income from Work
Retirement/Pension
TANF
SNAP
Unemployment
Worker's Comp.
Social Security/SSI
Alimony
Child Support
VA Benefits
Rent from Tenants
Cash assistance from family/others
Has your family experienced any of the following during the past two years? (check all that apply)
Illness
Death of family member
Separation/divorce from spouse or partner
Personal trauma/injury
Loss of home
Loss of employment
Physical abuse
Sexual abuse
Prison
Have any of the following behaviors presented concerns for your family? (check all that apply)
Relationship problems
Struggles with parenting
Conflict in household
Controlling temper
Gambling
Use of alcohol
Use of drugs
Stress
Traumatic event
School Problems
Eating Disorder
Depression/Mental Health
Physical Disability
Developmental Delay
Behavior Concern
Child Welfare Involvement
Does anyone in your family abuse alcohol or drugs? (check all that apply.)
Primary Caregiver
Spouse/partner
Child in household
OTHER HOUSEHOLD MEMBERS
List all individuals, other than yourself, who live in your household.
Household Member 1
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Head of Household:
*
Marital Status
Single
Married
Widowed
Separated
Divorced
Domestic Partner
Race
*
Caucasian (white)
Black/African American
Asian
American Indian
Hawaiian/Pacific Islander
Mixed Race
Unable to determine
Prefer not to answer
Other
Hispanic Origin
*
Hispanic
Non-Hispanic
Unable to determine
Gender
*
Male
Female
Other
Prefer not to Answer
Disability Status
*
Yes
No
Not Assessed
School Name
District
Grade
Student ID
Phone Number
-
Area Code
Phone Number
Are you enrolling this household member in GSCS services?
*
Yes
No
Household Member 2
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Head of Household:
*
Marital Status
Single
Married
Widowed
Separated
Divorced
Domestic Partner
Race
*
Caucasian (white)
Black/African American
Asian
American Indian
Hawaiian/Pacific Islander
Mixed Race
Unable to determine
Prefer not to answer
Other
Hispanic Origin
*
Hispanic
Non-Hispanic
Unable to determine
Gender
*
Male
Female
Other
Prefer not to Answer
Disability Status
*
Yes
No
Not Assessed
School Name
District
Grade
Student ID
Phone Number
-
Area Code
Phone Number
Are you enrolling this household member in GSCS services?
*
Yes
No
Household Member 3
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Head of Household:
*
Marital Status
Single
Married
Widowed
Separated
Divorced
Domestic Partner
Race
*
Caucasian (white)
Black/African American
Asian
American Indian
Hawaiian/Pacific Islander
Mixed Race
Unable to determine
Prefer not to answer
Other
Hispanic Origin
*
Hispanic
Non-Hispanic
Unable to determine
Gender
*
Male
Female
Other
Prefer not to Answer
Disability Status
*
Yes
No
Not Assessed
Phone Number
-
Area Code
Phone Number
School Name
District
Grade
Student ID
Are you enrolling this household member in GSCS services?
*
Yes
No
Household Member 4
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Head of Household:
*
Marital Status
Single
Married
Widowed
Separated
Divorced
Domestic Partner
Race
*
Caucasian (white)
Black/African American
Asian
American Indian
Hawaiian/Pacific Islander
Mixed Race
Unable to determine
Prefer not to answer
Other
Hispanic Origin
*
Hispanic
Non-Hispanic
Unable to determine
Gender
*
Male
Female
Other
Prefer not to Answer
Disability Status
*
Yes
No
Not Assessed
Phone Number
-
Area Code
Phone Number
School Name
District
Grade
Student ID
Are you enrolling this household member in GSCS services?
*
Yes
No
Household Member 5
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Head of Household:
*
Marital Status
Single
Married
Widowed
Separated
Divorced
Domestic Partner
Race
*
Caucasian (white)
Black/African American
Asian
American Indian
Hawaiian/Pacific Islander
Mixed Race
Unable to determine
Prefer not to answer
Other
Hispanic Origin
*
Hispanic
Non-Hispanic
Unable to determine
Gender
*
Male
Female
Other
Prefer not to Answer
Disability Status
*
Yes
No
Not Assessed
School Name
District
Grade
Student ID
Phone Number
-
Area Code
Phone Number
Are you enrolling this household member in GSCS services?
*
Yes
No
Household Member 6
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Head of Household:
*
Marital Status
Single
Married
Widowed
Separated
Divorced
Domestic Partner
Race
*
Caucasian (white)
Black/African American
Asian
American Indian
Hawaiian/Pacific Islander
Mixed Race
Unable to determine
Prefer not to answer
Other
Hispanic Origin
*
Hispanic
Non-Hispanic
Unable to determine
Gender
*
Male
Female
Other
Prefer not to Answer
Disability Status
*
Yes
No
Not Assessed
School Name
District
Grade
Student ID
Phone Number
-
Area Code
Phone Number
Are you enrolling this household member in GSCS services?
*
Yes
No
Household Member 7
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Head of Household:
*
Marital Status
Single
Married
Widowed
Separated
Divorced
Domestic Partner
Race
*
Caucasian (white)
Black/African American
Asian
American Indian
Hawaiian/Pacific Islander
Mixed Race
Unable to determine
Prefer not to answer
Other
Hispanic Origin
*
Hispanic
Non-Hispanic
Unable to determine
Gender
*
Male
Female
Other
Prefer not to Answer
Disability Status
*
Yes
No
Not Assessed
School Name
District
Grade
Student ID
Phone Number
-
Area Code
Phone Number
Are you enrolling this household member in GSCS services?
*
Yes
No
Household Member 8
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Head of Household:
*
Marital Status
Single
Married
Widowed
Separated
Divorced
Domestic Partner
Race
*
Caucasian (white)
Black/African American
Asian
American Indian
Hawaiian/Pacific Islander
Mixed Race
Unable to determine
Prefer not to answer
Other
Hispanic Origin
*
Hispanic
Non-Hispanic
Unable to determine
Gender
*
Male
Female
Other
Prefer not to Answer
Disability Status
*
Yes
No
Not Assessed
School Name
District
Grade
Student ID
Phone Number
-
Area Code
Phone Number
Are you enrolling this household member in GSCS services?
*
Yes
No
PROGRAM ENROLLMENT FORM
(*Indicates Required Field)
Participant Name (Household Member 1)
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Participant Name (Household Member 2)
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Participant Name (Household Member 3)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Participant Name (Household Member 4)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Participant Name (Household Member 5)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Participant Name (Household Member 6)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Participant Name (Household Member 7)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Participant Name (Household Member 8)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
EMERGENCY CONTACTS
The following individuals may be contacted in the case of an emergency.
Emergency Contact #1
*
First Name
Last Name
Relationship to Participant
*
Address
*
Phone Number
*
-
Area Code
Phone Number
Emergency Contact #2
First Name
Last Name
Relationship to Participant
Address
Phone Number
-
Area Code
Phone Number
Emergency Contact #3
First Name
Last Name
Relationship to Participant
Address
Phone Number
-
Area Code
Phone Number
Emergency Contact # 4
First Name
Last Name
Relationship to Participant
Address
Phone Number
-
Area Code
Phone Number
COMMUNICATION
*
YES, I would like GSCS to send me text messages and/or emails reminding me of important program activities/ events.
NO, I do not want GSCS to send me text messages and/or emails.
Good Samaritan Community Services (GSCS) utilizes an electronic communication tool, to share important program updates and reminders with families. This tool is used to remind participants and their families of important events such as program closures, parent meetings, scheduled conferences and home visits, and other program activities.
Initials
*
Clear
Permission to Participate in Water Activities
*
Yes
No
N/A
I give permission for my child to participate in water activities such as water play and swimming activities. I understand that I will receive prior notification of these events, and these activities will be guided by adult/staff supervision.
Permission to Walk Home
*
Yes
No
N/A
I give permission for my child (ren) to walk home.
Participation Agreement
*
Yes
No
N/A
Permission is given for the participant listed above to participate in Good Samaritan Community Services’ programs, planned assessments and activities. I understand that notification of special events and their requirements will be provided in advance. I also understand that not all participants may be chosen to participate in all special events. I also acknowledge that the participant listed above is fully able to participate in program activities and can function in a group environment.
Acknowledgement of Service Termination
*
Yes
No
N/A
I understand that failure to follow program guidelines may result in service termination.
Permission to Transport
*
Yes
No
N/A
I give permission for the participant listed above to be transported off-site by GSCS staff for the following purposes: 1) To participate in off-site activities including field trips; 2)To evacuate the campus due to weather or other emergency situations; and 3) To obtain emergency medical treatment.
Permission to Release Personal Data
*
Yes
No
N/A
I understand the data collected will be used for program evaluation purposes. I give permission for the records of the participant listed above to be shared for lawful reasons with other governmental or social services agencies. I understand that personal information will be held confidential and will not be released to anyone without my written authorization to do so.
Permission for Photography & Videotaping
*
Yes
No
N/A
I give permission for the participant listed above to be photographed or videotaped and for these photos, videos and personal success stories to be used in public media (TV, radio, newspaper, online media and other publications) to help inform the public about GSCS services
ORIENTATION TO PROGRAM SERVICES
I acknowledge I have been oriented to program services, either in person or through written communication (letter explaining program services and expectations and/or received a copy of the program handbook), that included program hours and days of operation, program procedures and participant expectations.
Initials
*
Clear
RELEASE OF LIABILITY
I hereby release Good Samaritan Community Services Staff and affiliates from all liabilities that may arise from accidental injury or damage to my or my child’s personal property. This includes, but is not limited to, all claims involving transportation to or from any activities and against any person or organization providing activities.
Initials
*
Clear
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
Clear
Save
Submit
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