Participant Info
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| Full Name* |
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| Are you native to Wayne County? |
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| If no, Please provide native location |
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| Address |
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| City |
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| State |
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| Zip Code |
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| How many people are living at this residence with you? |
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| Are you a… |
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| If a renter, Who is your landlord? |
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| Phone |
Your primary contact number
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| Email* |
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| Date of Birth |
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| Age |
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| Mailing List |
do you want to receive our newsletter and occasional announcements?
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| How many kids?* |
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| Name and Ages of Kids* |
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| Schools Kids Attend?* |
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| Are you a grandparent raising grandchildren? |
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| Former Address |
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| Former City |
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| Former State |
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| Former Zip |
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| Are you a member of a local church? |
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| Highest Level of Education |
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| Are you currently enrolled in secondary education? |
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| Employer |
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| If not Employeed most recent employer? Why were you let go? |
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| Are you a Veteran? |
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| Are you on disability? |
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| If yes, Explain |
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| Additional Contact Person |
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| Relationship with Contact Person |
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| Initial Reason for Requesting Assistance? |
What is the main reason for coming in today?
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| Photo ID* |
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| How did you hear about us?* |
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