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United Way’s Dual Generation Initiative Registration Form
Date
-
Month
-
Day
Year
Date
Personal Information
Name
*
First Name
Last Name
Last 4 of SSN
*
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Method of Contact
*
Phone Call
Text Message
Email
US Mail
Race
*
Black/African American
White
American Indian/Alaskan Native
Asian
Pacific Islander
Other
Declined
Ethinicity
*
Hispanic/Latino
Not Hispanic/Latino
Other
Declined
Gender
*
Male
Female
Non-Binary
Declined
Disability
*
Yes
No
Declined
Primary Language
*
Secondary Language
Criminal Background
*
None
Misdemeanor
Felony
Pending
Date of Conviction
*
-
Month
-
Day
Year
Date
How did you hear about Dual Generation?
*
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Household Information
Marital Status
*
Single
Married
Divorce
Partnered
Seperated
Widowed
Military Status
*
No Military Affiliation
Active Duty
Reserve
National Guard
Veteran
Spouse/Dependent of Service Member/Veteran
Household Size
*
Are you the head of household?
*
Yes
No
How many children ages 0-10?
*
Do any of your children have a disability?
*
Yes
No
Declined
If yes, who?
*
Yearly Household Income
*
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Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Next
Work and Education
Highest Education Level Completed
*
Highest Education Level Completed:
*
Please Select
No Formal Education
Elementary School
Middle School
Some High School
High School Diploma / GED
Some College
Associate Degree
Bachelor Degree
Master Degree
Doctorate Degree
Vocational / Trade School
Language Learning / ESL
Name of school where highest education was completed:
*
Date when Highest education was started:
*
-
Month
-
Day
Year
Date
Date when Highest education was completed:
*
-
Month
-
Day
Year
Date
Are you currently enrolled in school?
*
Yes
No
If yes, what is the Name of the Current School you are enrolled at?
*
If no, what type of education or training are you interested in?
*
Employment Status
*
Unemployed
Full-Time
Part-Time
Retired
Employer
*
Title
*
Industry
*
Start Date
*
-
Month
-
Day
Year
Date
Pay Amount
*
Pay Type
*
Salary
Hourly
Pay Frequency
*
Daily
Hourly
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Annually
Year-to-Date Earnings
*
Average Hours Worked
*
Frequency
*
Per Week
Per Month
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Would you be needing childcare assistance?
*
Yes
No
Are you interested in enrolling in Lantern (text notifications from KLRN)?
*
Yes
No
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are there any other services you or your family may need?
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