You Saved Me Florida Client Registration Intake Form

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You Saved Me Foundation is a 501 C3 Nonprofit Public Charity. All of our programs and services are free. We do not rely on government funding for our programs. Our services will not interfere with your public benefits. We do not report any of your private information to any government agencies or entities. Your information is securely stored in our cloud online. We believe in breaking barriers and assisting immediately. For this reason we do not require an ID or have any income restrictions on any of our programs and services. This form is for statistical data and inventory ordering for our clients. If you are requiring baby diapers please list all children in the household so we can provide what is needed.

Email *

Please follow the form and enter all information

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone Number *

Language Spoken

English

Spanish

Other:

Clear selection

Which Google Course would you like to register for? Please complete the Online application for a Google Scholarship , this will ensure the Course is free for you to complete. *

Google UX Design Certificate

Google Data Analytics Certificate

Google Project Management Certificate

Google IT Support Certificate

Associate Android App Developer

E-Commerce & Social Media Marketing Professional Certificate

CyberSecurity Certificate

Not Interested in Google Career Courses

Are you willing to commit 10 or more hours a week to complete the Free online Google Professional Career Certificate Course? *

yes

Required

If you register for the Google course, Are you willing to complete periodic progress reports (a. short summary on the programs benefits, and your progress) during the course and six months and after completion? And agree to complete the course and follow all guidelines and rules of the program? *

yes

Required

Which Free Support Service(s) would you like to have added to your You Saved Me Florida Membership? Check all that apply. Career and Financial Literacy programs are offered free online. Food and Hygiene can be accessed in person at local distributions. Be sure to check YouSaved.me/events for the most up to date events and distributions in your area. *

Food Pantry (Care Pantry Program)

Pet Food Pantry (More Than A Pet Program) (Cat& Dog Food Only)

Cat Food

Dog Food

Feminine Hygiene (Hi-Gene Program)

Maxi Pads

Tampons

Pantyliners

Opioid Overdose Prevention Training and a box of Free Narcan (Opioid Overdose Prevention Program)

Online Financial Literacy Courses (offered online)

Baby Diapers, Pull-Ups, & Wipes (Fresh Family Program)

Size 0

Size 1

Size 2

Size 3

Size 4

Size 5

Size 6

Size 7

Pull Up 2T-3T

Pull Up 4T-5T

Pull Up XXL

Teen Age Sleeper

Adult Diapers Small

Adult Diapers Large

Bed Pads

Required

Do you belong to any of the following groups? Check all that apply. *

Asylum Seeker / Refugee

Current Student

Did not complete High school

Immigrant/Migrant

Low-Income Individual or Low Income household member

Minority (person of color, women, LGBTQI+, disabled, religious minority, diverse ethnicity)

Single Parent

Prior Criminal History

Recently Released from Incarceration

US Veteran or Military Family Member

Required

Which best describes your Race/ Ethnicity? *

Asian/Pacific Islander

Black/ African American

Caucasian/ White

Hispanic/Latino

Indigenous/ Native American

Are you 16 years old or older? *

Yes

How old are you? *

Income Questions

Please answer the questions to the best of your ability

Monthly Income *

$2500 - $5000

$0- $500

$500 -$1000

$5000 +

$1000- $2500

Which best describes your joint Household income? *

My combined Household Income is Less Than $72,900 a year.

1 Person making less than $72,900 a year

2 People making less than $83,300 a year

3 People making less than $93,700 a year

4 People making less than $104,100 a year

5 People making less than $112, 450 a year

6 People making less than $120,800 a year

7 People making less than $129,100 a year

8 People making less than $137,450 a year

My household income exceeds the options the above.

What is your yearly income? If no Income answer with 0. *

List all Household Members Name, Birthdate, Relationship and Race (Ex. Jose Chavez, 10/23/1988, Son, Hispanic). If you are the only member type None. *

Please Type Your Name Below as Your Signature *

Your Birthdate *

YYYY

Quilgo Test ID *

This question is filled automatically ✋ DO NOT EDIT OR REMOVE

Submit

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