General Intake Form

Please complete the form below to request more information.

Contact Information

First Name

Last Name

Phone Number

What is your preferred method of contact? (phone or email)

Home Address

Address Line 1

Address Line 2

City

Zip/Postal Code

State

County

Business/Nonprofit Name

Race/Ethnicity Self-Identification

African American/BlackAsian/Pacific IslanderNative American/American IndianWhiteBiracial MultiracialOtherPrefer not to say

Other Race/Ethnicity

Do you identify as Latinx/Hispanic Origin?

YesNoPrefer not to say

Do you consider yourself an immigrant?

YesNoPrefer not to say

Do you consider yourself to have a disability?

YesNoPrefer not to say

Gender

MaleFemaleNon-BinaryPrefer not to sayOther

Other Gender

Birth Year

Are you a veteran?

YesNoPrefer not to say

How many adults live in your household?

How many children (under age 18) live in your household?

Total gross MONTHLY household income

.00

Household income is a measure of the combined incomes of all people sharing a particular household or place of residence. It includes every form of income, e.g., salaries and wages, retirement income, government benefits, etc.

How did you hear about LegalCORPS?

Flyer/BrochureOther Organization or EventSocial MediaFriend/FamilyInternet/Web SearchPartner ReferralOther

Which LegalCORPS Program(s) are you interested in?

Business & EntrepreneursEntrepreneurs of ColorInventorsNonprofit Organizations

Send me LegalCORPS updates, information relevant to my business/nonprofit/invention, and newsletters via email

Screening Type

Contact Information