Creating Conscious Communities with People Outside (C3PO) Intake Form
C3PO is an emergency response to the COVID-19 public health crisis. We are working to provide
temporary shelter and access to resources for people living outside. All houseless populations are encouraged to apply.

This form asks information about the identities you hold, your risk level for COVID, your ability/mobility needs and partner/tent partner information. We are asking this information in order to assess how we can best provide for your needs and respect the identities that you hold. This information is sensitive and will be kept strictly confidential between members of the intake committee.

We ensure our volunteers are vetted through a background check and 2 references, as well as existing community connections and shared commitment/values to the populations we are trying to organize for. Please let us know if you have any concerns about the following and need special accommodations

Please answer each question to the best of your ability.
Do you consent for us to release your name and contact info to whoever manages the camp? *
Do you consent for us to release your name and contact info to workers outside of the C3PO coalition to help provide access to housing resources? *
Are you filling out this form with a worker at an agency or organization who may be able to help contact you? If yes, what is their name and phone number? *
Your answer
Is it ok to leave a message with this person?
Are you currently camping in Old Town or downtown Portland? *
First Name that you use *
Your answer
Last Name *
Your answer
Pronouns *
Your answer
Age *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Do you have health insurance?
If so, who is your carrier?
Your answer
If you know your insurance ID number, please provide that here. If you don't know your ID number, you may skip this question
Your answer
Phone Number
Your answer
Best day/time to reach you and state preference for texting or phone call
Your answer
In case we can't reach you by phone or your caseworker and need to follow up with you about placement, where could we find you? *
Your answer
Are you Transgender/gender-non conforming/gender expansive/gender queer or cisgender? (Cisgender means that you identify with the sex you were assigned at birth) *
Do you identify as someone under the LGBTQAI2S+ umbrella? *
Intersex is a term for people born with atypical physical sex characteristics. There are many different intersex traits or variations. Do you have an intersex variation?
Gender (Check all that apply) *
Required
Race (Check all that apply) *
Required
In what language would you like us to speak with you in? *
Your answer
In what language would you like us to write to you in?
Your answer
Do you need a sign language interpreter? *
Are you a veteran (including anyone with dishonorable discharges)?
Do you have any pets? *
If yes, what kind of pet(s)?
Your answer
Would you prefer placement in a camp specific for people of color (POC)? *
Would you prefer a placement in a camp specific for lesbian, gay, bisexual, transgender, queer, intersex + (LGBTQAI2S+) people? *
Would you prefer a placement in a camp specific for lesbian, gay, bisexual, transgender, queer, intersex + (LGBTQAI2S+) people? *
If you prefer one of the POC/LGBTQ Affinity Camps but they are not available, are you okay with a placement in a camp with many different identities? *
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