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The information you provide us will be used specifically for the Human Services Grant that EmPOWERment, Inc. applies for every year for funding. Providing your name and contact information is optional and will only be used to connect you to resources when EmPOWERment, Inc. receives new information about programs. Your answers to the survey will not affect your rental application in any way if you have applied for one through EmPOWERment, Inc.
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Today's Date
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DD
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YYYY
First Name
Your answer
Last Name
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Phone number
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Email Address
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Reason for visiting EmPOWERment,Inc
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Affordable Housing
Emergency Fund
Career Explorer
Other:
Please list the number of people within the age range provided that our currently in your house of residents (including yourself)
Age
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0
1
2
3
4
5
Males 0-5 Years
Female 0-5 Years
Males 6-18 Years
Females 6-18 Years
Males 19-50 Years
Females 19-50 Years
Males 51+ Years
Females 51+ Years
0
1
2
3
4
5
Males 0-5 Years
Female 0-5 Years
Males 6-18 Years
Females 6-18 Years
Males 19-50 Years
Females 19-50 Years
Males 51+ Years
Females 51+ Years
Ethnicity
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African-American
American Indian or Alaska Native
Asian
Caucasian
Hispanic/Latino
Native Hawaiian or Pacific Islander
Other
Geographical Location
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Town of Chapel Hill
Town of Carrboro
Town of Hillsborough
City of Mebane (Orange County)
Orange County (Outside Municipalities)
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