Friendly Center · Holiday Pre-Registration Form

Primary Caregiver Information

Name

*

First Name

Last Name

Phone

*

Email

Verify Email

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Have you or any member of your family served in the military?

*

Yes

No

Are you currently able to meet the basic needs of your household?

*

Yes

No

Do you have time and resources to help your children with homework?

*

Yes

No

N/A

In the past year, did you run out of food before you could buy more?

*

Yes

No

What is your primary language?

*

How did you hear about Friendly Center?

*

Please list all family members living in your home in the table below, beginning with yourself:

Family Member 1:

First Name

Last Name

Relationship to Client

Date of Birth

(mm/dd/yyyy)

Gender

Male

Female

Ethnicity/Race

Disabled

Yes

No

Insurance

Family Member 2:

First Name

Last Name

Relationship to Client

Date of Birth

(mm/dd/yyyy)

Gender

Male

Female

Ethnicity/Race

Disabled

Yes

No

Insurance

Family Member 3:

First Name

Last Name

Relationship to Client

Date of Birth

(mm/dd/yyyy)

Gender

Male

Female

Ethnicity/Race

Disabled

Yes

No

Insurance

Family Member 4:

First Name

Last Name

Relationship to Client

Date of Birth

(mm/dd/yyyy)

Gender

Male

Female

Ethnicity/Race

Disabled

Yes

No

Insurance

Family Member 5:

First Name

Last Name

Relationship to Client

Date of Birth

(mm/dd/yyyy)

Gender

Male

Female

Ethnicity/Race

Disabled

Yes

No

Insurance

Are there more than 5 members of your family?

*

Yes

No

Which Friendly Center location is closest to you?

*

6688 Beach Blvd, Buena Park

147 W Rose Ave, Orange

When is the best time to contact you?

*

Monday: 11:30am-8pm

Tuesday: 9am-5:30pm

Wednesday: 11:30am-8pm

Thursday: 9am-5:30pm

Friday: 9am-5:30pm

Friendly Center staff will call you to complete your Holiday Registration. They will call you a maximum of 2x. If you do not answer, they will move on to the next client.