Client Application
Date
-
Month
-
Day
Year
Date
New Client or Client Re-Certification
New Client
Client Recertification
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
example@example.com
Date of Birth
Last 4 of Social Security
HouseHold Information
Please check all CFS Services you would like to hear more about?
Food Pantry
Energy Assistance (EAP)
Weatherization
Huntington House Homeless Shelter
Empower
Senior Citizen Employment Program (SCEP)
Thrift Store
WIC
Head Start
Rapid Housing/Homeless Prevention (RRHHP)
Housing Choice Voucher (HCV) Section 8
Rental Assistance
Emergency Food Delivery
Silver Lining
Is YOUR Household Income below the federal poverty guidelines?
Yes
No
Are You looking for job opportunities?
Yes
No
Are You looking to further your education?
Yes
No
Do You need internet access?
Yes
No
Do You need computer access?
Yes
No
Are You homebound for any health related reasons?
Yes
No
Are You/Your family quarantined due to Covid-19?
Yes
No
Are You /You family self quarantining in fear of Covid-19?
Yes
No
Total number of household members under age 18?
Total number of household members over the age of 18?
Total number of household members over the age of 65?
Signature
Submit
Should be Empty: