Legal Aid ELED
Webinar
Registration Form
In order to make our workshops free for you, our funder asks for the following information.
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Monday, September 16, 12:00 Noon
Monday, September 16, 5:30 PM
Please tell us about yourself.
First Name
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Gender
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Do you speak English fluently?
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What is your Household's Primary Language?
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What is the Street Number of your Residence (numbers only)
What is the name of the road you live on?
Do you have an Apartment Number or Apartment letter? (if applicable)
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In which state do you reside?
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What is the Zip Code of Residence?
Is your mailing address different from your physical address?
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Primary Phone Number
Do you receive text messages on this phone?
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Personal Email
**
Please note
if you need an accommodation or a support person to attend with you please contact our office to make the necessary arrangements. – education@getahome.org or 861-7394 **
Is someone else registering for the webinar with you?
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Co-Registrant (if applicable)
First Name
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Birthdate
Mobile Phone Number
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HOUSEHOLD INFORMATION (We need to know who is living in your home.)
Is anyone else living with you in this household? (Do NOT include yourself or any other webinar attendee listed above.)
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Additional Household Member
Household Member Name
Household Member Birthdate
What is their relationship with you?
Child
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Is anyone else living with you?
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Second Additional Household Member
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Is anyone else living with you?
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Third Additional Household Member
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Is anyone else living with you?
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What is your Living Situation
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Do you live in a CHT Property?
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CHT Renter
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Define your Household type
Single Adult
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Is anyone in your household disabled or have special needs?
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