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PUHC Involvement Form

How To Get Involved

First Name

Last Name

Phone Number

Email Address

Why Would You Like To Get Involved?

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Email: info@computerarepair.com

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1 out of 2 forms

Sign-Up Form

Contact Information

First Name

Last Name

Address

City

Zip Code

Phone

Phone Type

Email

Emergency Contact

Emergency Contact #

Relationship

Demographic Information

Date of Birth

Age

Gender

Martial Status

Authorixed to work in US

Citizen of U.S Alien/ Refugee Lawfully Admitted to U.S. U.S. Permanent Resident No

Considered to be of Hispanic heritage:

Yes No

Race Ethnicity

American Indian/Alaskan Native, Asian, Black or African American, Native Hawaiian/Other Pacific Islander, White, American Indian/Alaskan AND White, Asian AND White , Black or African American AND White, American Indian/Alaskan Native AND White,

Employment Information

Employment Status

Education Information

Highest School Completed

Elementary Middle School 9th 10th 11th 12th, did not graduate High School Graduate/ Equivalent Some College AA BA

English Language Learner

Public Assistance/ Barriers

Supplemental Security Income (SSI)

Supplemental Nutrition Assistance Program (SNAP / EBT)

TANF

General Assistance (GA)

Homeless

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Phone

Email