Registration Form

The information you provide is confidential and will be treated accordingly.

By filling out this form, you consent to receive services from Mountain Resource Center and forever discharge the Mountain Resource Center from all liability for any injury or loss caused by participation in these services.

	Yes	No	Not Applicable
Does your household have difficulty accessing enough food without assistance?
Is your housing unstable? Do you have trouble paying rent?
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?

Contact Information

Male	Female
Non-Binary	Prefer Not To Say

American Indian or Alaska Native	Asian
Black / African American	Hawaiian Native / Pacific Islander
Multiracial	White
Other	Prefer Not To Say

Phone	Email
Do Not Contact	No Preference

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

None	SNAP	Medicaid	TANF
SSI	SSDI	Other

Spouse	Partner	Child	Grandparent	Grandchild
Family	Friend	Other	Self	Guardian
Ward	Foster Parent	Foster Child