New Customer Registration Form

New Client Registration Form

Creating Pathways
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
How would you like to be contacted

Other
Creating Pathways, a 501(c)3 organization (EIN: 33-2706961)

Creating Pathways, a 501(c)3 organization (EIN: 33-2706961)
Race/Ethnicity
Tribal Affiliation
Gender
2Spirit | LGBTQIA+
Veteran/Branch of Service
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Nature of your request(s) and/or need(s)

Are you currently working with another Agency or Program for similar or other services?

Rows	Agency/Program Name	Type of Services
1
2
3
4
5

Creating Pathways, a 501(c)3 organization (EIN: 33-2706961)
How are you feeling about the following?

Please rate your satisfaction in the following areas (1=worst, 5=best)
Money/Finances
Digital Literacy
Housing Stability
Employment
Work/Career
Friends/Family
Community
Overall Well-being

Creating Pathways, a 501(c)3 organization (EIN: 33-2706961)
What lead you to reach out?
What do you hope to gain?
Is there anything additional you would like to share?

Creating Pathways, a 501(c)3 organization (EIN: 33-2706961)
Client Commitment

I agree to commit to working the program. I understand that this is my Journey, and Creating Pathways is here to partner with me along this Journey, they are not here to do the work for me. I understand that I must do my part to make this a success. I will take the necessary step along this journey.
Initials
Organization Commitment
We are committed to protecting your privacy. This policy explains how we collect, use, and safeguard your information, in accordance with Washington State law.

We may collect Name, address, phone, email, Demographic info (e.g., race, language, income), Health data (with consent), Case notes and service history
Website data (e.g., IP address)

We use your information to Provide services, Communicate updates, Fulfill legal or funding requirements and Improve our programs

We may share your data with Staff or volunteers (as needed), Partner organizations (with agreement), Funders (aggregated/anonymized)

You may request access to your data, ask us to correct or delete data, withdraw your consent, and ask how your data is used

We use secure systems and train our staff. We keep data only as long as necessary under the law

We DO NOT collect data from youth under 18 as our Programs are not designed for these individuals

We update this policy as laws or practices change, Most recent version always available by request or on our website (https://creating-pathways.org)

By signing below, you agree that Creating Pathways may need to share your contact information with aligned Partners, so that we can work together with you to insure you have all available Resources for the bettement of You!

Contact us anytime at info@creating-pathways.org
Signature
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New Client Registration Form

How are you feeling about the following?

Client Commitment

Organization Commitment