Road to Success New Client

Todays Date

Date

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County of Residence

DauphinCumberlandPerry

Number of children under the age of 18 living in the home

Ethnicity

Marital Status

Education

Barriers (please select all that apply)

ChildcareTransportation - bus passSkills Enhancement/Training/EducationOther

Have you signed up to ELRC to receive childcare?

YesNo

Do you have sufficent clothing for a potential interview?

YesNo

To provide you with the best service possible, Family Promise Harrisburg Capital Region will keep track of the services and support we provide to you and your household. This also allows us to advocate for you better and properly connect you with resources. To do this, your information will be stored securely and only accessible to authorized Family Promise staff and program partners who are directly involved in helping meet your needs. Your information will not be shared with outside agencies or individuals without your permission, except as required by law.

Road to Success Checklist