Building One Community -

B1C Intake Form

"*" indicates required fields

This application is for:*

Have you been to B1C before?

Yes

B1C Number (If known)

How did you hear about B1C?*

Your Name*

First Name Middle Name Last Name

Second Last Name

Address*

Street and Apartment City State ZIP Code

Mobile Phone*

Unsubscribe from all SMS communication

We use SMS to inform you of our upcoming programs and events. Message and data rates may apply. Please check the box below If you DO NOT want to receive marketing SMS messages.

I DO NOT want to receive marketing text messages from Building One Community.

Other Phone

Your Email

Birthday*

Gender*

Emergency Contact

Name

First Name Last Name

Phone

Relationship

Further information about you

Ethnicity/ Race*

Asian

Black or African American

Caribbean

Hispanic or Latino

Middle Eastern or North African

White

Other

What is your preferred language?*

What country were you born in?*

Year arrived in the US*

Marital Status

Education Completed*

Employment Status*

WhatsApp Status Updates

We also update our WhatsApp Status regularly to inform about our upcoming programs and events and other community announcements. Please save our B1C Outreach number (475) 333-9216 in your contacts to view those WhatsApp Status updates.

Media Policy

We have engaged a photographer to take photos during our programs, classes, and when providing services at Building One Community (B1C). These photos will be used for B1C marketing purposes, including, but not limited to, the website, brochures, digital newsletters, social media, posters, and other printed materials and will not be sold or licensed to any third parties unaffiliated with B1C. If you have children under the age of 18 years and do NOT want your child’s photo to appear in B1C's marketing materials, please email us their names at info@b1c.org

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Consent

I give consent

I DO NOT give consent

Do you have children under the age of 18 who live in the United States?*

Yes

Information about your children

Please list any children under the age of 18 who live in the United States. Please provide them in the order of birth.

Child 1 Information

Second Last Name

Relationship to child*

Gender*

School*

Child 2 Information

Second Last Name

Relationship to child

Gender

Child 3 Information

Second Last Name

Relationship to child

Gender

FOR INTERNAL USE ONLY

Staff members, please provide your name if you helped fill out this form.

Staff Member Name

First Last

This field is for validation purposes and should be left unchanged.