Winter Glow Intake Form

Fill out the form below to pre-register for Winter Glow.

The information you provide is confidential and helps us improve Winter Glow.
You can skip questions you are not comfortable answering.

Contact Info

Preferred Name

Preferred Pronouns


What is your most reliable address?


Current Need

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

How many children are in your household?

What was your household income last month?

Languages comfortable speaking

Veteran Status

Do you have a disability?

Have you applied for CAC services before

Highest Level of School Attended?

Housing Situation


Birthdate (mm/dd/yyyy)




Once you click ‘submit’ you are pre-registered for Winter Glow. Thank you!