San Juan Chapter House Assessment
Please fill out this form Completely. It is for our REGISTERED Voters and San Juan Chapter Members. This questionnaire will be strictly classified. It will help us better understand your needs and how we can approach them.
Please state your Full Name, be sure to include a Phone Number that we may reach you at; your mailing address (P.O. Box, City/State/Zip code) and a physical address.
Are you registered to San Juan Chapter House?
Are you a Registered Voter? If yes, please include your Censes # below.
Are there any individuals in your home over the age of 18? Are they registered to vote at San Juan Chapter House? If yes, please include their Name and Census Number below.
Are you and/or anyone else living in your home a Veteran?
Are there any elders currently living with you? Do they have any special needs? Please state their name and age.
If possible, may you please list all of your vendor(s) below? Examples: Allaround Propane, NTUA, Tse Bit'Ai Propane, etc.
What kind of assistance are you seeking today? Please check a maximum of 3.
Assistance with Utility Bills
Assistance with Rent
How would this assistance benefit your family?
Does your current living location have a Homesite Lease? Is the Homesite Lease in your name?
If you do not have running water or electricity, what can we do to assist you? Do you need water bottles, water jugs, flashlights, solar energy, etc.? Please Explain below,
This is for any child living in your home currently.
Click HERE if this bottom portion is not applicable to you.
This portion is not applicable to me.
How many children are in your home?
Are there any infants? If so, how old?
How many of them are in school currently?
Are they learning remotely or online?
Do you utilize the School Bus lunches that the Central Consolidated School District provides?
Please use the space provided below to State your child(ren)'s name, age and their grade. You may also use their Academic Position as well; College, High School, Middle School, Elem. Pre-k, Etc.
What assistances would benefit them, so that they may continue their education? Please check a maximum of 3.
Please insert your Email Address if you have one.
You may use this space for any comments or recommendations. We appreciate your time!
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