Center for Changing Lives: Workshop Registration / Formulario de admisión

Please provide us with the following information. Information collected on this form is used by Center for Changing Lives only and is not shared with any other organization, unless requested for reporting and funding purposes. Your personal information is never shared. Please answer all questions completely. If you have any questions about this form or how we will use this information, please ask us.
What workshop are you registering for? *
Date of workshop: *

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Unit/Apartment Number

CityState

Zip Code
Email*
example@example.com
Alternate Contact Name & Info:*
PERSONAL INFORMATION
Date of Birth:*

MonthDayYear
Date
Cell Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
Veteran Status:*
Are you 60 years or older?*
Marital Status:*

Single (never married)MarriedPartneredSeparatedDivorcedWidowed
Gender*

FemaleMaleTransgenderNonbinaryOther
Race*

African American / BlackCaucasian / WhiteAsianAmerican Indian / Alaskan NativeMore than oneOtherChoose not to respond
Ethnicity*

Non-HispanicHispanicChoose not to respond
Do you have a criminal background?*

Misdemeanor(s) onlyFelony or feloniesBothN/A
HOUSEHOLD INFORMATION
Are you the head of household?*

YesNo
Limited English Proficiency: Are you fluent in the English language?*

YesNoChoose not to respond
How many in your household (include yourself)?*
In total household, include the head(s) of the household and the people you are financially responsible for.
How many under the age of 18? *
What language do you most often speak at home?*

EnglishSpanishPolishOther
Household Type*

Married with childrenMarried without childrenDomestic partnershipMale-headed single parentFemale-headed single parentSingle adultTwo or more unrelated adultsOther
Living Arrangement*

I rent a housing unitI stay in a unit for freeI own my own house/apartmentI rent with other households in an overcrowded unitI am living on the street or in a shelter
What types of cash income are received by any person in the household and who receives what income?*

Unemployment compensationEmployment & otherEmployment ONLYTANF / (AFDC)Social Security IncomePensionEarnFareChild SupportNo IncomeSocial Security Disability InsuranceOther
Are you working now?*

YesNo
Total Gross Monthly Household Income:*
In the past 12 months, how many full months (4 consecutive weeks) did you work?*
If employed, name of employer:*
Do you live in a rural area?*

YesNoChoose not to respond
MEDICAL INFORMATION
Are you currently insured?*

YesNo
If you are currently insured, which are you receiving?

MedicaidMedicareCountyCarePrivate insurance
Are you disabled?*

YesNoChoose not to respond
PROGRAM INTEREST
What is your primary interest in our services?*

Job Placement / Career DevelopmentIncome Support / Public BenefitsFinancial Education / CounselingHousing Education / Counseling
Are you a first-time homebuyer?*

YesNo
How did you hear about us?*
HUD DISCLOSURE
Center for Changing Lives is a nonprofit, HUD-approved, comprehensive housing counseling agency. We serve all clients 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 housing counseling program participant, you are not obligated to use the products and services of Center for Changing Lives or our industry partners.
Member Signature:*
Thank you! This information, when combined with all other participant information without your name or identifying information, helps us improve our services! Your responses will be kept confidential.
Should be Empty:

PERSONAL INFORMATION

HOUSEHOLD INFORMATION

MEDICAL INFORMATION

PROGRAM INTEREST

HUD DISCLOSURE