CHA Workshop Registration

Participant Information:

Name *

First Name Last Name

Age *

Gender: *

Male Female

Phone Number *

Area Code Phone Number

Email Address: *

example@example.com

How did you hear about us:

Online Social Media Friend/Family Organization

Are you a HCV holder? ( Housing Choice Voucher - Section 8)

Yes No

Address *

Current Address

Apt #

City State

Zip Code

Have you live in this address for more than 6 month?

Yes No Currently facing homelessness

Race (check only one): *

American Indian / Alaskan Native Black/African American Asian Asian and White Native Hawaiian or other Pacific Islander White

Ethnicity: *

Hispanic Non-Hispanic Choose not to respond

Number of People in Household: *

How many people live in your home?

Number of Dependents:

How many people do you claim in your income tax?

Preferred Language: *

Household Annual Income: *

$0.00 - $15,000 $15,001 - $30,000 $31,000 - $45,000 $46,000 - $60,000 $61,000

February Workshops