Intake Form
Language Preference/Preferencia de Idioma
*
Please Select
English/Ingles
Spanish/Español
Other
Which county are you living in?/¿En qué condado vive?
*
Please Select
Adams
Grant
Other
Have you submitted an application for assistance before?/¿A presentado una solicitud de asistencia anteriormente?
*
Please Select
Yes/Si
No/No
I don't know/No sé
How can we reach you?/¿Como podemos contactarlo?
*
By phone/Por telefono
By email/Por correo electrónico
I don't have either/No tengo ninguno
Name/Nombre
First Name/Nombre
Last Name/Apellido
Your current address/Where are you currently staying/did you last stay?/¿Dirección actual/En donde se esta quedando/donde fue el ultimo lugoren que se quedo¿
Street Address/Domicilio
Street Address Line 2/Domicilio linea 2
City/Ciudad
State / Province/Estado/Provencia
Zip Code/Codigo postal
Phone Number/Número de teléfono
-
Area Code
Phone Number
Email/Correo electrónico
example@example.com
What is your age?/¿Edad?
Please Select
0-14
15-17
18-24
25-34
What is your gender?/¿Género?
Female/Femenino
Male/Masculino
Other (e.g. non-binary, gender fluid, etc.)/Otro (por ejemplo, no binario, fluido de género, etc.)
Decline to answer/Negarse a contesta
Race/Raza
Black, African American, or African/Negro, Afroamericano, o Africano
Asian or Asian American/Asiático o Asiático Americano
White/Blanco
Native Hawaiian or Pacific Islander/Nativa Hawaiana o isleña del Pacifico
American Indian, Alaska Native, or Indigenous/Indio Americano, navtivo de Alaska o Indigena
I don't know/No sé
Other
Ethnicity/Etnicidad
Please Select
Hispanic/Latin(a)(o)(x)
Non Hispanic/Latin(a)(o)(x)
I don't no/No sé
Decline to answer/Negarse a contesta
Does anyone in your household have a disability?/¿Alguien en su hogar tiene una discapacidad?
Please Select
Yes/Si
No/No
I don't know/No sé
Decline to answer/Negarse a contesta
Is anyone living/staying with you?/¿Alquien vive/se queda con usted?
Please Select
Yes/Si
No/No
I don't know/No sé
Decline to answer/Negarse a contesta
Is anyone in your household pregnant?/¿Alquien en su hogar esta embarazada?
Please Select
Yes/Si
No/No
I don't know/No sé
Decline to answer/Negarse a contesta
Is anyone in your household a veteran?/¿Alquien en su hogar es un veterano?
Please Select
Yes/Si
No/No
I don't know/No sé
Decline to answer/Negarse a contesta
What is your source of income?/¿Fuente de ingreso?
Please Select
No income/Sin ingresos
Working income/Ingresos laboraesl
Retirement income/Ingresos de jubilacion
Decline to answer/Negarse a contesta
If you have an income, how much to you make per month?/¿Si tiene un ingreso?
Please verify that you are human/Por favor vertifique que es humano
*
Submit
Should be Empty: