CCILC EVENT REGISTRATION FORM 2023

1

ATTENTION: For consumers only or those willing to become consumers! You must be a person with a disability residing in Camden City. Call our office for more information at 856-966-0800.

Registering for an event does not guarantee you a spot, some programs have limited space. Once your registration form is recieved a staff member will contact you to let you know if you are able to participate.

Registering for an event and failing to attend may result in you being ineligible for future events.

2

Are you a consumer?* This field is required.A consumer is a person with a disability who lives in Camden City, and is already registered with our office for services. If you are not already a consumer, but would like to become one, please contact our office at 856-966-0800.

Yes

No

Willing to become a consumer

3

Are you a person with a disability?* This field is required.This can include but is not limited to physical impairment, sensory impairment, cognitive impairment, intellectual impairment, mental illness, and various types of chronic disease.

Yes

No

4

Do you live in Camden City, New Jersey* This field is required.

Yes

No

5

Full Name* This field is required.

First Name

Last Name

6

Address* This field is required.If you live in an apartment complex please include the name of the apartment complex as well.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

Phone Number* This field is required.

Please enter a valid phone number.

8

Email

example@example.com

9

Children's Program* This field is required.MUST HAVE CUSTODY OF THE CHILDREN OR BE THEIR LEGAL GUARDIAN TO REGISTER A CHILD. NO EXCEPTIONS

Joys of Toys for Rae's Kids Age range 0-10 years old

Pajama and Book Giveaway (ongoing) Up to age 10 years old

Pencil Project Up to age 14 years old

Spring and Summer Bag (Ongoing) Age Range 0-10 years old

Scientists at Home Program (Ongoing) Up to age 10

Learning and Environmental Education Program

None

11

Do you have access to a reliable computer?A computer is required for Young Adult Social Program, Drivers ED, and Minecraft Coding Workshops

YESNO

12

Holiday EventsSpace is limited to the first 25 registrants

Turkey Palooza (November)

None

Coat Giveaway (November)

Can Good Giveaway (December)

Hat and Glove Give Away (December)

13

Coat GiveawayPlease complete only if you have registered for the coat giveaway.

Consumer Name

Age

Gender

Size

Person 1

Person 2

Person 3

Person 4

Person 1

Person 2

Person 3

Person 4

Consumer Name

Age

Gender

Size

Consumer Name

Age

Gender

Size

Consumer Name

Age

Gender

Size

Consumer Name

Age

Gender

Size

14

Holiday EventsSpace is limited to the first 25 registrants

Turkey Palooza

None

Coat Giveaway

15

Covid-19 Programs and Events* This field is required.Free

Face Mask (ongoing)

Vaccine Transportation Program (ongoing)

None

16

Life Skills* This field is required.Age Range (18+)

Zoom Training

Drivers Education

Money Management

Emergency Preparedness: Go Bag Program (December)

Housing Assistance Workshops (ongoing)

Many Roads 2 Recovery

None

17

How many people live in your household?This includes yourself and anyone you have custody of. Please do not list people for whom you are not responsible such as roommates or other families sharing your living space.

18

How many people live in your household?* This field is required.This includes yourself and anyone you have custody of. Please do not list people for whom you are not responsible such as roommates or other families sharing your living space.

19

HOUSEHOLD INFO: This section is used for children's programs and COVID-19 services, skip if it is not applicable.Must have custody of the children listed below or be their legal guardian. NO EXCEPTIONS

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Shoe Size

Boy or Girl

Age

1

2

3

4

5

1

2

3

4

5

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Shoe Size

Boy or Girl

Age

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Shoe Size

Boy or Girl

Age

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Shoe Size

Boy or Girl

Age

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Shoe Size

Boy or Girl

Age

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Shoe Size

Boy or Girl

Age

20

Do you have custody of the child(ren) listed above?* This field is required.

No

Yes

Not Applicable

21

Due to the pandemic many of our services are virtual or drive-thru events. If the event you are interested in participating is a drive-thru event, will you have access to a ride or transportation?* This field is required.

22

Person completing the application* This field is required.Please type your full name

23

Date* This field is required.

Date

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I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me from services or cause a delay in assistance. * This field is required.

Full Name