Registration Form
SHARE Program
In order to make our workshops free for you,
our funders ask for the following information.
Please tell us about yourself.
First Name
Middle Initial
Last Name
Birthdate
What is your Marital Status?
Please select...
Single
Married/Domestic Partner
Separated
Divorced
Widowed
What is your Race?
Please select...
Caucasian/White
American Indian/Aleut/Eskimo/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
Multiple Race
Race not listed
Chose not to respond
Are any members in your household Black, Indigenous, People of Color? (BIPOC)
Yes
No
What races/ethnicities live in your household? Please select all that apply.
Caucasian/White
American Indian/Aleut/Eskimo/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
Race Not Listed
Hispanic/Latino/Latina/Latinx
What is your Ethnicity?
Hispanic
Not Hispanic
I choose not to respond
Gender
Please select...
Male
Female
Transgender
Other
Is anyone in your household disabled or have special needs?
Yes
No
Were you born a U.S. Citizen?
Yes
No
Are you actively serving in the Military?
No
Yes
Are you a Veteran?
No
Yes
Education
Please select...
Less than High School Diploma
High School Diploma or equivalent
Some Post-High School Education
Certification from a Vocational or Technical Training Program
Associate's Degree
Bachelor's Degree
Master's or other Graduate Degree
Is someone else attending with you?
Yes
No
Co-Client (if applicable)
First Name
Last Name
Birthdate
Mobile Phone Number
2nd Person Email
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 attendee listed above.)
Yes
No
First Household Member
Household Member Name
Household Member Birthdate (optional)
What is their relationship with you?
Child
Spouse
Non-married Partner
Other Relative
Not Related
Is anyone else living with you?
Yes
No
Second Household Member
Household Member Name
Household Member Birthdate (optional)
What is their relationship with you?
Child
Spouse
Non-married Partner
Other Relative
Not Related
Is anyone else living with you?
Yes
No
Third Household Member
Household Member Name
Household Member Birthdate (optional)
What is their relationship with you?
Child
Spouse
Non-married Partner
Other Relative
Not Related
Is anyone else living with you?
Yes
No
Fourth Household Member
Household Member Name
Household Member Birthdate (optional)
What is their relationship with you?
Child
Spouse
Non-married Partner
Other Relative
Not Related
Is anyone else living with you?
Yes
No
Fifth Household Member
Household Member Name
Household Member Birthdate (optional)
What is their relationship with you?
Child
Spouse
Non-married Partner
Other Relative
Not Related
Is anyone else living with you?
Yes
No
Sixth Household Member
Household Member Name
Household Member Birthdate (optional)
What is their relationship with you?
Child
Spouse
Non-married Partner
Other Relative
Not Related
Is anyone else living with you?
Yes
No
Seventh Household Member
Household Member Name
Household Member Birthdate (optional)
What is their relationship with you?
Child
Spouse
Non-married Partner
Other Relative
Not Related
Is anyone else living with you?
Yes
No
Eighth Household Member
Household Member Name
Household Member Birthdate (optional)
What is their relationship with you?
Child
Spouse
Non-married Partner
Other Relative
Not Related
Is anyone else living with you?
Yes
No
Ninth Household Member
Household Member Name
Household Member Birthdate (optional)
What is their relationship with you?
Child
Spouse
Non-married Partner
Other Relative
Not Related
Is anyone else living with you?
Yes
No
Tenth Household Member
Household Member Name
Household Member Birthdate (optional)
What is their relationship with you?
Child
Spouse
Non-married Partner
Other Relative
Not Related
Define your Household type
Single Adult
Female-headed single parent
Male-headed single parent
Married-No dependents
Married-with dependents
Two or more unrelated adults
Other
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)
What is your City of Residence?
In which state do you reside?
Please select...
VT
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
WA
WV
WI
WY
What is the Zip Code of Residence?
Do you own a CHT Shared Equity Home?
Please select...
Yes
No
Is your mailing address different from your physical address?
Yes
No
Second address (if needed)
Mailing Street
Mailing City
Mailing State
Please select...
VT
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
WA
WV
WI
WY
Mailing Zip
Mobile Phone Number
Do you receive text messages on this phone?
Yes
No
Home Phone Number (land line)
Which phone number is your Primary Phone?
Please select...
Home
Mobile
Personal Email
Gross Annual Income (Combine the income of all members in your household)
Please enter a number without any commas.
Confirmation
By typing my name below, I confirm that I have received and read Champlain Housing Trust's
Privacy Policy
&
Conflict of Interest Statement
.
If you have questions about this form, please contact us at
education@getahome.org
or 802-861-7394.
Contact Information