2026 In-Person Intake Form
Clallam Mosaic
Participant Name
*
First Name
Last Name
Gender
*
Male
Female
Non-binary
Date of Birth
*
-
Month
-
Day
Year
Date
Legal status(choose one)
*
Minor
Guardianship
Independent
Other
If you chose "other" for level of independence, please clarify
Phone Number
*
Please enter a valid phone number.
Can we text phone?
Yes
No
Phone Number
Enter a second contact number if you have one.
Can we text phone?
Yes
No
Participant's Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your preferred method of receiving program information:
Text
Email
Paper
Living Status
*
Live alone with paid care providers
Live alone with family providing care
Live alone, no care providers
Live in group home or supported living facility with paid care providers
Live in shared housing with one roommate
Live in shared housing with multiple roommates
Live with family
Companion Home
Other (Please clarify)
If you chose "other" for living status, please clarify
Is the participant's mailing address the same as the home address?
*
Yes
No, please fill in mailing address below
Mailing Address (Complete if different from home address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Name of Emergency Contact
*
First Name
Last Name
Phone - 1st Emergency Contact
*
Please enter a valid phone number.
Email - 1st Emergency Contact
example@example.com
Name of Second Emergency Contact
*
First Name
Last Name
Phone # - 2nd Emergency Contact
*
Please enter a valid phone number.
Email - 2nd Emergency Contact
example@example.com
Name of person completing form
*
First Name
Last Name
Signature - By signing below, the person completing this form attests that the information provided is true, accurate and complete to the best of his/her knowledge.
*
To complete registration, the following forms are needed:
Filled out once for 2026
2026 In-Person Intake Form
2026 Health Status Form
2026 Health Liability Release Waiver
2026 In-Person Code of Conduct
2026 Participant Consent Form
Submit
Should be Empty: