Raising The B.A.R. Families Strengthening Program Intake Form

Today's Date *

Participant's First Name *

Participant's Middle Name

Participant's Last Name *

Last 4 digits SSN *

Age *

Gender *

Date of Birth *

Street Address *

City *

ZIP code *

Primary Phone Number *

Is this a cell/mobile phone? *

Email Address *

Parental Marital Status *

What primary role do you play as a parent, guardian, or primary caregiver? (Please select only one) *

Country of Birth *

Please note that The Children's Services Council of Broward County may contact you via postal mail, email and/or text to ask about your satisfaction with services, and to make you aware of other funded programs, initiatives and events that may interest you.

How many children are in your care? *

Child 1 Full Name *

Child 1 Information *

Country of Birth
Last 4 of SSN
Date of Birth
BCPS Student ID #

Child 2 Full Name

Child 2 Information

Country of Birth
Last 4 of SSN
Date of Birth
BCPS Student ID #

Child 3 Full Name

Child 3 Information

Country of Birth
Last 4 of SSN
Date of Birth
BCPS Student ID #

Employment Status *

Total Annual Household Income *

What is your preferred language for contact? (Please select only one) *

What language(s) do you feel comfortable communicating at home? (Select all that apply) *

Describe your Cultural Influence

Do you identify as Hispanic or Latina/o/x? *

Do you identify as Haitian? *

Race (Please select one) *

What is the highest level of education you've completed? *

How were you referred to the program? *

PARTICIPANT SIGNATURE *

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