Rose Francis Foundation New Client Intake Form
Please complete this form to receive access to our services.
Date
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Month
-
Day
Year
Date
Section 1: Identification of Primary Applicant
Name
First Name
Middle Name, Last Name
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Driver's License or Birth Certificate
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Section 2: Demographic of Primary Applicant
Sex
Please Select
Female
Male
Transgender
Intersex
Non-Binary
Ethnicity
Please Select
Hispanic or Latino
Non Hispanic or Latino
Race
Please Select
Alaskan American Native American
Native Hawaiian/Pacific Islander White
Black/African American ❏ Latino/Latinx
2 or More Races
Asian
Section 3: Family Information
Family Status
Please Select
Single Parent with Children Under 18
Single Parent with No Children Under 18
Single Person No Children Under 18
Two Parent with Children Under 18
Two Parent with No Children Under 18
Family Size (Including Primary Applicant)
Please Select
1
2
3
4
5
6
7
8
9
10+
Source of Income
Please Select
None
Employment
Government Assistance
Please explain current state or federal assistance programs you and your family use as income
Total Income per Year (include all incomes of each working person in home)
Housing Status
Please Select
Housed
Unhoused
Evicted
Section 4: Others Living In Home
Adult #2 ID, Birth Certificate, or SSN
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Adult #3 ID, Birth Certificate, or SSN
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Adult #4 ID, Birth Certificate, or SSN
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Child #1 ID, Birth Certificate, or SSN
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Child #2 ID, Birth Certificate, or SSN
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Child #3 ID, Birth Certificate, or SSN
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Child #4 ID, Birth Certificate, or SSN
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Child #5 ID, Birth Certificate, or SSN
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Child #6 ID, Birth Certificate, or SSN
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Section 5: Desired Service
Which services will you are your family be needing
Food Pantry, Clothing Closet
Emergency Financial Assistance
Virtual Behavior Training
Community Resources
IMPORTANT Program Information
If your family will be using the Food Pantry and Clothing closet please complete our Food Preference Form on our website. If your family will be using the Emergency Financial Assistance program please complete our request form on our website. If your family will be using the Online Behavior Training program please locate training available for purchase or sliding scale on our websites online store. If your family will be using the Community Resource program please contact haja@rosefrancisfoundation.org with your specific needs to be sent a community resource list within three business days.
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