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Workshop Registration Form | Formulario de inscripción para el taller
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* Indicates required question
Preferred Language || Lenguaje Preferido
*
English
Español
Required
First Name || Nombre
*
Your answer
Last Name || Apellido
*
Your answer
Street Address || Dirección
*
Your answer
Apartment Number || Número de apartamento
Your answer
City || Ciudad
*
Your answer
State || Estado
*
NY
Other:
Zip Code || Código Postal
*
Your answer
E-mail Address || Correo Electrónico
*
Your answer
Cell Phone number || Numero de Teléfono
*
Your answer
Household Size || Tamaño de hogar
*
Your answer
Age of Head of Household || Edad del Jefe/Jefa del Hogar
Choose
18-20
21-30
31-40
41-50
51-60
61-70
71+
Not Provided
Annual Income || Ingreso Anual
*
Choose
$ 0 - $4,999
$5000 - $9,999
$10,000 - $14,999
$15,000 - $19,999
$20,000 - $24,999
$25,000 - $29,999
$30,000 - $34,999
$35,000 - $39,999
$40,000 - $44,999
$45,000 - $49,999
$50,000 - $60,000
$60,000 - $70,000
$70,000 - $80,000
$80,000 - $90,000
$90,000 - $100,000
Ethnicity ||
Etnicidad
White (non hispanic origin)//Blanco(origen no hispano)
Asian or Pacific Islander//Asiatico
Black//Negro
Hispanic (Latino)//Hispano
Other//Otro
Building Type || Tipo de Edificio Donde Vive
NYCHA/public housing
Big building (6 or more apartments)
Small Builiding (6 or less apartments)
House//Casa
Shelter//Refugio
Roommate/Comparte apartamento
Living with Family//Vive con Familia
Homeless//en la calle
Other:
Housing Issues || Problemas de Vivienda
Eviction//Desalojo
Unable to afford rent//No puede pagar renta
Hot Water//Agua Calient
Heat//Calefaccion
Lease//Contrato de Renta
Landlord Harassment//Acoso de parte del arrendador
Construction//Constuccion
Buyout//Compra del apartamento
Mold//molde o mojo
Flooding/Leaks//Inundaciones
Rodents/pests//ratones/plagas
Other:
How much are you paying for rent? ||
¿Cuánto estás pagando
de renta?
Your answer
Do you have. a voucher? ||
¿
Tiene un Cupon de renta?
Section 8
HASA
LINC
FHEPS
No
Other:
Voucher amount || Monto del Voucher
Your answer
Credit Rating ||
Calificación crediticia
Bad//Malo
Moderate//Moderado
Good//Bueno
I don't know//No se
How did you hear about CUFFH? ||
¿Cómo se enteró de CUFFH?
Church//Iglesia
Facebook
Website//Pagina Web
News//Noticias
Internet
Friend/Family//Un amigo o familiar
Event//Evento
Organizing
Local Elected's Office
Community Based Org
Other:
Are you registered to vote? || ¿
Estás registrado para votar?
Yes
No
Workshop Selection || Selección de Taller
*
English 4:30pm-6pm
Español 6:30pm-8pm
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