Emergency Air Conditioner Screening
You must fill this form out COMPLETELY AND CORRECTLY TO RECEIVE SERVICES AND LIVE IN PORTLAND AREA
Are you a miracles client
*
yes
no
Name
*
First Name
Last Name
Date of Birth
*
Email
*
example@example.com
Address
*
Street Address
PLEASE WRITE IN YOUR APT NUMBER!!!!!! NOT WRITING YOUR APT NUMBER WILL DELAY YOUR APPLICATION
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
DO YOU HAVE AN AIR CONDITIONER IN YOUR HOME?
*
YES
NO
a. Do you or an household member have underlying health problems
*
Yes
No
b. Are you employed?
*
Yes
No
c. Receive SNAP Benefits
*
Yes
No
d. Have an elder in your home over 60?
*
Yes
No
e. Have a new born or child under 3 in your home?
*
Yes
No
How many people live in your home: (for example 3 kids, 1 adult) Please be specific how many children younger than 18 and how many adults.
*
What is your race
*
Black
White
Hispanic
Native American
Asian
MIXED W/ BLACK AND SOMETHING ELSE
Other
What is your gender
*
female
male
non binary
Other
Date FILLED OUT
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: