Registration - Birthright Living Legacy

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Intake Registration

First Name *

Last Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone Number *

Date of Birth *

Are you a Veteran

Yes
No

Income Level *

$0-$25,000
$26,000-$44,000
$45,000-$60,000
$61,000-$80,000
$81,000 and up
Other

Race *

Black/African American
White
Native American
Latin X
Mixed Race
Choose no to answer
Other

How many children do you have? (Count Adult Children) *

0
1
2
3
4
5
6+

1st Child Age *

2nd Child Age *

3rd Child Age *

4th Child Age *

5th Child Age *

Write the Age of each additional child. Separate with comma *

Number of Male children *

Number of Female Children *

Number of Other Children (sexual identifications) *

How many of your children are under the age of 8? *

Relationship Status *

Unmarried
Married
Divorced
Widowed
Other

Highest level of education? *

Some High School
High School Diploma
Some College/ Trade School
College Degree
Other

Engagement *

In Home - Lives with children
Out of Home - Lives Separate from children
Legal (Supervise visits or court interaction)
Legal (But unable to see due to financial obligations)
Other

Religious Affiliations (optional disclosure - all are welcome)

Have you ever participated in organized sports? *

Yes
No

If yes to sports, how long?

What do you hope to gain from these meetings? Click all that apply *

Community
Leadership Skills
Networking
Financial Support (Basic Needs)
Legal Help
Supervised Visits
Parenting Skills
Fatherhood Resources
Counseling Referral
Other

Are you in court? *

Yes
No

Do you have an attorney? *

Yes
No

Are you seeking assistance? *

Yes
No

Are you on supervised visits? *

Yes
No

Is there a protective order in place? *

Yes
No

Have allegations been made against you? *

Yes
No

Are there any accusations for you against a child?

Are there protective orders in place? If yes, what is the charge? *

Are there any accusations for you against a child?

Help us understand what matters to you. Use this section to share anything you would like for us to know that we have not already covered?

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