First Page

First Name

Last Name

Phone Number

Email

What is your most reliable address?

Street

State/Province

Zip

County
--None-- Dane Jefferson Waukesha Other

Second Page

How many adults are in your household? (including yourself):

How many children are in your household?

What was your household income last month?

Birthdate (mm/dd/yyyy)

Last Page

Have you applied for CAC services before
--None-- Yes No Unknown

Housing Situation
--None-- Rent, with no subsidy Rent, with ongoing subsidy Own Other Permanent Housing Doubled up Homeless/Shelter Other Unknown

Gender
--None-- Female Male Transgender Gender Non-Conforming (i.e. not exclusively male or female) Non-Binary Other Unknown Prefer not to say

Do you have a disability?
--None-- Yes No Prefer not to say

Ethnicity
--None-- Hispanic/Latinx/Spanish Origins Not of Hispanic/Latinx/Spanish Origins Unknown

Race
--None-- Asian/Southeast Asian Black/African American Native American/Alaskan Native Native Hawaiian/ Pacific Islander White/Caucasian Multi-Racial Other Unknown