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Home
Services
Mountain Resource Center New Client Registration
Basic Needs, Emergency Financial Assistance & More
Food Pantry, Mobile Food Share & Community Health
Early Childhood & Family Education
Public Benefits Enrollment Assistance
Veterans Support Services
Events Calendar
About Us
About MRC
Equity, Diversity and Inclusion Statement
Official MRC Video
Take a Virtual Tour
Volunteer
Careers
Board of Directors
Financials and Annual Reports
Client Stories
Bowls After Dark ~ Roaring 20s Fundraiser 2021
Resale Store
Contact Us
Mountain Resource Center New Client Registration
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Mountain Resource Center New Client Registration
Registration Form
Primary Contact Information
First Name / Nombre
Last Name / Apellido
Birthdate/Fecha de nacimiento
Gender-Género
Please select...
Male
Female
Non-Binary
Prefer Not To Say
Are you a veteran?
Please select...
Yes
No
Race/ Raza
Please select...
American Indian or Alaska Native
Asian
Black / African American
Hawaiian Native / Pacific Islander
Multiracial
White
Other
Prefer Not To Say
Of Hispanic, Spanish or Latino origin?
¿De origen hispano, español o latino?
Please select...
Yes
No
Don't Know
Household Information
Preferred Contact Method/¿Método de contacto preferido?
Please select...
Phone
Email
Do Not Contact
Email Address / Correo Electrónico
Phone / Número telefónico
Address / Dirección
City / Ciudad
Zip / Código Postal
Total Monthly Income/
¿Ingreso mensual?
What is your current living situation?
Please select...
Living in car
Living in RV/Tent
Living with Friends/Family
Living in a Shelter
Living in a Rented Home
Living in a Owned Home
Current benefits received-Beneficios recibidos
Please select...
None
SNAP
Medicaid
TANF
SSI
SSDI
Other
Yes
No
Not Applicable
Does your household have difficulty accessing enough food without assistance?
Is your housing unstable?
Are any adults in your household unemployed/ underemployed?
Are there members of your household that do not have access to a medical provider?
Are there members of your household without health insurance?
Do you want parenting support and resources?
Would you like to receive the newsletter?
What Parenting support are you interested in?
Please select...
Incredible Years
Circle Of Parents
I don't know
How many people live in your household, including you? / ¿Cuántas personas viven en su hogar, incluido usted?
Additional Family Members
First Name / Nombre
Last Name / Apellido
Birthdate/Fecha de nacimiento
Race/ Raza
Please select...
American Indian or Alaska Native
Asian
Black / African American
Hawaiian Native / Pacific Islander
Multiracial
White
Other
Prefer Not To Say
Of Hispanic, Spanish or Latino origin? /
¿De origen hispano, español o latino?
Please select...
Yes
No
Don't Know
Gender/Género
Please select...
Male
Female
Non-Binary
Prefer Not To Say
Relationship to Primary Contact/
Relación con el contacto principal
Please select...
Spouse
Partner
Child
Grandparent
Grandchild
Family
Friend
Other
Self
Guardian
Ward
Foster Parent
Foster Child
Is this household member a Veteran?
Please select...
Yes
No
Contact Information
** MRC'S ANNUAL FUNDRAISER IS THURSDAY, SEPTEMBER 8 **
PURCHASE CASINO NIGHT TICKETS HERE