ALL PROGRAMS (EXCEPT FOOD BANK) INTAKE (ALL HOUSEHOLD SIZES)

El Centro de la Raza is a voice and a hub for Seattle and Martin Luther King Jr. County’s Latino community as we advocate on behalf of our people and work to achieve social justice. Through our comprehensive programs and services, we empower members of the Latino community as fully participating members of society. We also work to raise awareness with the general public, and government, business and civic leaders about the needs of the Chicano/Latino community in the United States.

Our organization has a strong commitment to the struggle for civil rights for all persons, regardless of race, and a rich history of services to the community. Many of our program participants come back to El Centro de la Raza to join our advocacy efforts, to volunteer, or just to visit. Along with our local work, we maintain an international perspective and connections and continue to work for positive social change in the global community.

Email of Staff Entering Intake

This is the email to which the response confirmation and summary will be emailed.

Use this section to add the Primary Contact or Guardian for the household. While the questions are not required, please do your best to capture accurate information.

PRIMARY PARTICIPANT

Program Enrollment

Program Record Type PC

First Name

Middle Initial (no period)

Last Name

Suffix

Preferred Name

Preferred Phone

Mobile

Home Phone

Work Phone

Subscribe to text messages from us. You can expect to receive 2-3 messages per month and can opt-out at any time by texting the word STOP.

YesNo

Preferred Email

Personal Email

Work Email

Alternate Email

Date of Birth

Gender

Ethnicity

Race

Primary Language

Education Level

Military status

Do you have a disability?

Employment Status

Are you a immigrant or refugee or new arrival to this country?

Are you limited in your ability to communicate in English?

Staff, please ask the participant if they are already registered to vote. If they are not, please register them to vote.

What is your voter registration status?

Do you have more household members to enter?

YesNo

Use this section to add additional household members. At the bottom of the section you'll see a link titled "Add Another Household Member", click the link if you need to add a 3rd, 4th, 5th... household member to the intake.

ADDITIONAL HOUSEHOLD MEMBERS

Program Enrollment

Program Record Type HH Contact

First Name

Middle Initial (no period)

Last Name

Suffix

Preferred Name

Preferred Phone

Mobile

Home

Work

Preferred Email

Personal Email

Work Email

Alternate Email

Date of Birth

Gender

Ethnicity

Race

Primary Language

Education Level

Military status

Do you have a disability?

Employment Status

Are you a immigrant or refugee or new arrival to this country?

Are you limited in your ability to communicate in English?

Staff, please ask the participant if they are already registered to vote. If they are not, please register them to vote.

What is your voter registration status?

ADDRESS INFORMATION

Primary Address

Mailing Street

Mailing City

Mailing State

Mailing Zip/Postal Code

HOUSEHOLD CHARACTERISTICS

Housing Status

If homeless, please provide former zip code

Number of members in family/household

Household composition

Do you have health insurance?

What type of health insurance do you have?

Do you have a primary health provider?

Did you have an annual check-up with a physical health care provider during the previous 12-months

Did our staff assist you with finding a provider or health-related service?

For single parents or custodians: Child support services may be available to you. Do you need more information or a referral to these services?

Child support information provided

HUD INCOME GUIDELINES

Please select the HUD income category that best matches your household (far left column)

HHS INCOME GUIDELINES

Please select the HHS income category that best matches your household (far left column)

ALL PROGRAMS (EXCEPT FOOD BANK) INTAKE (ALL HOUSEHOLD SIZES)

HOUSEHOLD CHARACTERISTICS

HUD INCOME GUIDELINES

HHS INCOME GUIDELINES

CASH BENEFITS

NON-CASH BENEFITS

Thank You for taking time to complete our intake form!!!