Community Response Application for Assistance
As a part of the evaluation of Community Response, your data will be shared with Nebraska Children & Families Foundation and their evaluators at the Munroe-Meyer Institute. Your name will not be included with any of the information that is provided to the evaluation team. All data is summarized as a group. You can choose not to participate in the evaluation. All information is kept confidential within the York County Community Coalition.
I agree to have my information shared for the purpose of the evaluation.
*
I agree
I do not agree
Signature
Name
*
Primer nombre
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there someone who DOESN'T live with you we can contact if we can't reach you? Please enter a name and phone number.
What is your race?
*
Please Select
White
Black or African American
Hispanic or Latino
Asian
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
Other
What is your gender?
*
Male
Female
Prefer not to say
Birthdate
*
-
Month
-
Day
Year
Date
What is your most urgent need?
*
Daily Living
Medical/Dental Needs
Education
Employment
Finances
General Life Skills
Housing
Legal Help
Mental Health
Substance Use
Transportation
Utilities
Other
Please give a description of WHAT & WHY you are seeking assistance.
I currently receive the following types of public assistance (Select all the apply):
*
Aid to Dependent Children/TANF
Child Care Subsidy/Title XX
Food Stamps (SNAP)
Housing Voucher/Section 8
Medicaid
Unemployment
Utilities Assist./LIHEAP/LIWEAP
WIC
None
Other Food Services (Food Pantry, etc.)
Other
Do you or your children QUALIFY for Medicaid, Title XX, and/or free and reduced lunch, even if you don't receive any of them?
*
Yes
No
Employment Status:
*
Employed full time
Employed part time
Unemployed
Employer for applying adult:
*
Employer for secondary adult in the household:
Do you have enough people to count on when you need someone to give you good advice? Please enter how many. If you have none, enter 0.
As of today's date are you between the ages of 14 and 25 (have not yet had your 26th birthday)?
*
Yes
No
ONLY if you answered yes, have you experienced any of the following?
Foster Care/State Ward/Placed outside of the home
Probation or Incarceration
Homelessness
In-home services for your family from DHHS
Human Trafficking
Guardianship or Adoption
None of these
Prefer not to say
How many adults in your household? (18 and older)
*
How many children (17 and younger) Enter 0 if no children live in your household
*
Do you have a disability?
*
Yes
No
Do any of your children have a disability?
*
Yes
No
If yes, how many?
Are you currently pregnant or expecting a child (mother or father)?
Yes
No
Do you have children that participate in any of the following?
Head Start/Early Head Start
Sixpence
Do you have an open and court involved case with DHHS?
*
Yes
No
Submit
Submit
Should be Empty: