EMERGENCY ASSISTANCE PROGRAM
Registration Form
Name
*
First Name
Last Name
Address (This program is only available to HIGH DESERT Families Living in Adelanto, Victorville)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Marital Status
*
Single
Married
Age group
*
17 and under
18-24
25-40
41-55
56+
Race/Ethnicity
*
African American
Asian
Caucasian
Hispanic
Native American
Pacific Islander
Other
Programs of Interest: Programs listed with an * require participants to meet all eligibility requirements.
*
*Car seat Education / Supplies
*Emergency Food Assistance
*Emergency Utility Assistance
Financial Literacy
Nutritional Education
Proof of Eligibility & Income
Proof of income:
*
Check Stub
SSI Award Letter / Statement
Unemployment Award Letter / Statement
Other / Public Assistance
Proof of residence:
*
California Driver's License / ID
Other:
Are you currently employed
*
Yes
No
Are you a United States citizen?
*
Yes
No
If no, are you authorized to work in the United States?
*
Yes
No
Have you ever received car seat / food / or utility assistance from CHAN in the past?
*
Yes
No
Household Members
Enter amount of people in your household
*
Important
Community Health Action Network does not discriminate in admission or access into programs on the basis of race, color, religion, gender, age, marital status, disability, political beliefs, national or ethnic origin in the recruitment, selection, treatment or termination of clients.Statistical Demographic Data: The information above must be completed by the applicant in order to participate in program services. This confidential data is used for funding and reporting to the Federal Emergency Management Agency (FEMA) purposes only. Please complete the information outlined below for applications into the following programs: Car Seat Education / Supplies, Emergency Food Assistance, Emergency Utility Assistance.
I understand that completing a Financial Literacy class is a requirement to receive Utility Assistance through CHAN. I also confirm that all information provided on this form is true and accurate to the best of my knowledge.
*
Yes
No
Signature
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