Family Center Registration Form

FAMILY CENTER REGISTRATION FORM
Agency Client ID:
Name: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail: *
example@example.com
Best way to contact you:

Phone Email
My primary language:

English I need an interpreter I need an American Sign Language interpreter
Living arrangements:

Rent Own a home Stay with relatives/friend Shelter
How would you describe your household?

Single adult, no children Couple, no children Single Parent, female Single Parent, male Two Parents with children Guardian(s) caring for children Foster parent(s) with children Relative(s) caring for children
How did you hear about our parenting and family programs? (Check all that apply)

Health Center Staff Friend/Relative Internet Insurance Directory/Phone Book Family Center Staff Social Service Agency School Newspaper/Radio/TV Medical/Other Professional Flyer/Brochure/Poster Hospital
Important Note:

Most of the organizations that provide funding for our programs require us to report on race and average income levels of the people who use our programs. Your information will not be shared in connection with your name—it will only be shared in the form of summaries about the people we serve.

Please complete the tables and sign below to verify the information you are providing. Thank you.

Household Members

Begin with your-self, include all adults and children who live with you (first and last name).

This person’s relationship to you

Gender

Date of Birth
(mm/dd/yy)

Highest grade completed (Adults)

Race

Are You Hispanic?

US Military Service?

Our Health or Dental client?

Self

Annual Household Income:

Please find the number of people in your household, then move across and check your income in that row.

1 Person

0 – $19,140 yr.

$368/wk.

$19,141 yr. $25,520 yr.

$369/wk. — $490/wk.

$25,521 yr. $38,280 yr.

$491/wk. — $736/wk.

Over $38, 281 yr.

Over $737/wk.

2 People

0 - $25,860 yr.

$497/wk.

$25,861 yr. $34,480 yr.

$498/wk. — $663/wk.

$34,481 yr. $51,720 yr.

$664/wk. — $995/wk.

Over $51,721yr.

Over $996/wk.

3 People

0 - $32,580 yr.

$627/wk.

$32,581 yr. $43,440 yr.

$628/wk. — $835/wk.

$43,441 yr. $65,160 yr.

$836/wk. — $1,253/wk.

Over $65,161 yr.

Over $1,254/wk.

4 People

0 - $39,300 yr.

$755/wk.

$39,301 yr. $52,400 yr.

$756/wk. — $1007/wk.

$52,401 yr. $78,600 yr.

$1008/wk. — $1,511/wk.

Over $78,601 yr.

Over $1,512/wk.

5 People

0 - 46,020 yr.

$885/wk.

$46,021 yr. $61,360 yr.

$886/wk. — $1,180/wk.

$61,361 yr. $92,040 yr.

$1,181/wk. — $1,770/wk.

Over $92,041 yr.

Over $1,771/wk.

6 People

0 - $52,740 yr.

$1014/wk.

$52,741 yr. $70,320 yr.

$1015/wk. — $1,352/wk.

$70,321 yr. $105,480 yr.

$1,353/wk. — $2,028/wk.

Over $105,481 yr.

Over $2,029/wk.