Building One Community -

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B1C Number (If known)

How did you hear about B1C?*

Second Last Name

Mobile Phone*

Other Phone

Your Email

Birthday*

Gender*

Emergency Contact

Phone

Relationship

Further information about you

What is your preferred language?*

What country were you born in?*

Year arrived in the US*

Marital Status

Education Completed*

Employment Status*

How many people are in your household?

Information about your children

Please list any children under the age of 18 who live in the United States.

Second Last Name	Relationship to child	Is this child born in the US?	Child’s Birthdate	Gender	School	Actions

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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

FOR INTERNAL USE ONLY

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

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B1C Intake Form Dupe

Emergency Contact

Further information about you

WhatsApp Status Updates

Media Policy

FOR INTERNAL USE ONLY