EADC Intake Form 
Please fill out the following questions for our office to arrange you with the best resources that can best serve you and your household. 
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First Name  *
Last Name
Address (street, city, state, zip code)  *
Email *
Phone Number  *
What is the best way to contact you? 
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Race *
Required
Including yourself, how many people currently live in your household?  *
How many of your household members are people under the age of 18?  *
Which of the following resources would be beneficial for you and your household?  *
Required
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