Workshop Intake Form

Workshop Intake Form
Select Workshop*
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Work Phone
Cell Phone
Email*
example@example.com
Referred From:
example@example.com
Primary Language
Race/Ethnicity (select all that apply)

African American/BlackAsianCaucasion/WhiteHispanic/Latino/ChicanoNative American/Native AlaskanNative Hawaiian/Pacific IslanderOther
Gender

MaleFemaleOther
Education
Marital Status
Household Type
Do you rent or own your home?
Are you the head of household?

YesNo
Are you foreign-born?

YesNo
Are you a U.S. Citizen?

YesNo
Are you a Veteran?

YesNo
Are you Active Military?

YesNo
Are you Disabled?

YesNo
Are you a Disabled Dependent?

YesNo
Are you a first-time homebuyer?

YesNo
Are you a first-generation homebuyer?

YesNo
Employer
Job Title
Annual Household Income
Monthly Client Gross Income
Monthly Client Net Income
Co-Applicant (if applicable)

Please include spouse or other adult household member who may be sharing household expenses
Relationship to client
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
Please enter a valid phone number.
Race/Ethnicity (select all that apply)

African American/BlackAsianCaucasion/WhiteHispanic/Latino/ChicanoNative American/Native AlaskanNative Hawaiian/Pacific IslanderOther
Gender

MaleFemaleOther
Employer
Job Title
Monthly Co-applicant Gross Income
Monthly Co-applicant Net Income
Is co-applicant disabled?

YesNo
Agreements & Disclosures
Would you like to receive information about MCCA events?

YesNo
Initial by each document to confirm that you have received the following documents.
IL Department of Human Rights Fair Housing
Enter Initials*
For Your Protection: Get a Home Inspection (HUD 92564-CN)
Enter Initials*
Ten Important Questions to Ask Your Home Inspector
Enter Initials*
Disclosure of Lead-Based Paint Hazards in Housing (EPA-747-F-96-002)
Enter Initials*
Confidentiality Notice

Please note that all information is kept confidential and personally identifying information will not be shared with any other individuals or agencies without your prior written consent. MCCA is required to share compiled demographic information and outcomes with funders or for research purposes; however, the information shared is a compilation of data received from all participants, does not include personally identifying information, and will not personally identify any individuals or families.
Disclosure

MCCA is a non-profit, HUD-approved, comprehensive housing counseling agency. We serve all customers regardless of income, race, color, religion/creed, sex, national origin, age, family status, disability, or sexual orientation/gender identity. We administer our programs in conformity with local, state, and federal anti-discrimination laws. As a workshop attendee or counseling customer, you are not obligated to use the products and services of MCCA or our industry partners.
Signature*
Today's Date*

MonthDayYear
Date
Please verify that you are human*
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Workshop Intake Form

Co-Applicant (if applicable)

Agreements & Disclosures