CARE for AIDS Client Intake Data
Name of Community/ Center *
Program Phase (for pilots)
Program Year
Name *
Your answer
Age *
Your answer
ID Number *
Your answer
Gender *
How many dependent children do you have under the age of 19 years old? *
Do you accept Jesus as your personal Lord and Savior?
OBSERVATION: Comments (if any) regarding client's answer to previous question:
Your answer
Do you regularly attend a local church?
Never submit passwords through Google Forms.
This form was created inside of CARE for AIDS. Report Abuse - Terms of Service