Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone *

(###)

###

####

Alternate Phone

(###)

###

####

Best time to call? *

Day

Evening

Country of origin (check all that apply):

United States

Other

Gender (check all that apply):

Man

Woman

Other

How do you identify (check all that apply):

Asian

Black/African-American

White/Caucasian

Native American/Indigenous

Pacific Islander

Latino/Latina/Hispanic

More than one race

Additional Race/Ethnicity

Which describes you? (check all that apply)

I am an immigrant

I have applied for asylum

I am a refugee/asylee

I am undocumented

I am a permanent resident

I am on a student visa

Unknown / Prefer not to answer

Please check what we can provide to you to help you attend the CAB meetings:

Transportation help getting to meetings

Wheelchair access

Child care during meetings

A non-English or sign language interpreter

Something else

If yes, what services have you ever used at Amani (formerly known as Crime Victim Care CVC): (check all that apply)

Network for Safe Families/Community Partners Services

Counseling/Therapy Services

Department of Child Services

Substance Use Support Services

Victim Care Services

Group Education Services

Internship Participant

Other

Phone Number of Reference 1:

(###)

###

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Phone Number of Reference 2:

(###)

###

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