Central Intake form - Coastal Georgia Area Community Action Authority Inc.

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Home
About
Services
- Central Intake form
- Community Services
Rise Risley
- Rise Risley Photos
- Rise Risley Calendar
Events
Give
- Volunteer Program

Central Intake Form

Community Action's Mission is to improve the quality of life for families through education, training, comprehensive services and advocacy. Tell us how we can better serve you. Please complete this form below with all necessary information pertaining to your house hold.

* Indicates required field

Name *

First

Last

Date of Birth *

Phone Number *

Alternate Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Mailing Address (if Different from Physical address) *

Line 1

Line 2

City

State

Zip Code

Country

Housing Status: *

Are you living in a homeless situation? *

Yes No

Are you a U.S. Citizen or Authorized to work in the U.S.? *

Yes No

Race *

Black Hispanic Native American White Other

If other, Please Identify: *

Do you have access to transportation? *

Yes No

Monthly Household Income *

Household Size *

Source of Income: check all that apply *

SSI TANF Retirement Disability Employment No Income Self-Employment

Highest Level of Education Obtained *

Veteran *

Yes No

County of Service *

Weatherization Services *

Critical Home Repairs Energy Efficient Upgrades

Early Childhood Education Services *

Expecting Mother 6 weeks old - 3 year old 3 year old - 5 year old

Community Services *

Case Managment Education Housing Utilities Assistance Financial Empowerment Income Tax Preperation Youth Development Aging Services Women's Empowerment

Additional Comments and/or request? *

How did you hear about Community Action? *

If other please identify: *

This agency is subject to certain nondiscrimination recordkeeping and reporting requirements which require the agency to invite clients to voluntary self-identify their ethnicity, race, U.S. citizenship and veteran status. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders and regulations including those which require the information to be summarized and reported to the Federal Government.

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Contact
1 Community Action Drive, Brunswick, GA 31520
Phone: (912) 264-3281 Fax: (912) 265-7444

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