Mi Casa Business Pathways Registration Form

We would like to ask some questions about you and your household. The information you provide will be kept confidential and used by Mi Casa to serve you better. Providing us this information allows us to continue to offer free and low-cost services to you and the rest of the community. Please answer all questions to the best of your knowledge. 
Hidden
Personal Contact Information

Please enter your personal contact information, not the contact information for your business.



Please enter your home address
Please enter your personal email address
Please enter your primary personal phone number
###-###-####

Demographic Information


Educational & Professional Experiences




Please enter your personal annual income for each category. If a category does not apply to you, enter $0.

If you do not know your annual income for a category, please enter the amount you make/receive on a weekly, bi-weekly, or monthly basis in the category box and select that frequency.









TANF, SNAP, SSI/SSDI, etc


Social security, investment accounts, etc


If this number is not correct, please adjust the income categories above
Household Information




Including yourself, how many of the people in your household are...


If this number is not correct, please adjust the age ranges above


Please enter your household members' combined annual income for each category. Do not include your own personal income.
If your household members have no income in a category, enter $0.

If you do not know the annual income for a category, please enter the amount they make/receive on a weekly, bi-weekly, or monthly basis in the category box and select that frequency.









TANF, SNAP, SSI/SSDI, etc


Social security, investment accounts, etc


If this number is not correct, please adjust the income categories above

Business Pathways Registration

Business Information
Please give us a percentage
Please give us a percentage

Maximum of 80 characters allowed.
Business Contact Information





Releases

Agreement to SBA Communication
Mi Casa Releases

Photo, Video, and Audio Release


Mi Casa likes to share stories of our participants to foster hope and inspiration in the community, as well as giving insight into the work we do. Will you give your consent to Mi Casa and its partners to use photographs, video footage, audio recordings, and written testimonials for the purpose of advertising, marketing, or discussing the organization's work?

Release of Liability

I understand the activities may have an element of hazard and inherent danger, and I take full responsibility for the actions and physical condition of myself. I hereby release and forever discharge Mi Casa and Mi Casa's officers, directors, and employees of any liability, claim, or damage for any injury or loss I may incur by my participation. In the event of an emergency, I give permission to transport myself to a hospital and to secure medical care. 

Information Sharing

Information collected from registration forms, questionnaires, and meetings with staff and partners may be used confidentially to help Mi Casa and its partners to evaluate and coordinate services. I grant permission to Mi Casa and its partners to share data confidentially among each other and with outside evaluators for the purpose of evaluating and coordinating services.


By electronically signing and entering today's date below I am certifying that I am the person who has completed the information on this form, that to the best of my knowledge, the information on this registration form is true, and I am aware of the release of liability, information sharing, and photo, video, and audio release statements above. Should you have a problem or complain regarding Mi Casa's programming or staff, please contact Mi Casa's Chief Operating Officer at (303) 573-1302. 
Electronic Signature

I agree that by typing my full name in the box below and entering today's date, I am electronically signing this form.


Mi Casa Resource Center
345 S Grove St, Denver, CO 80219
Main Line: (303) 573-1302
Business Hours: Mon-Thurs 8 a.m. - 6 p.m. | Fridays 8 a.m. - 4:30 p.m.
http://www.micasaresourcecenter.org/ | info@MiCasaResourceCenter.org