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San Juan Chapter House Assessment
Please fill out this form Completely. It is for our REGISTERED Voters and San Juan Chapter Members. This questionnaire will be strictly classified. It will help us better understand your needs and how we can approach them.
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* Indicates required question
Please state your Full Name, be sure to include a Phone Number that we may reach you at; your mailing address (P.O. Box, City/State/Zip code) and a physical address.
*
Your answer
Are you registered to San Juan Chapter House?
*
Yes
No
Are you a Registered Voter? If yes, please include your Censes # below.
*
Your answer
Are there any individuals in your home over the age of 18? Are they registered to vote at San Juan Chapter House? If yes, please include their Name and Census Number below.
Your answer
Are you and/or anyone else living in your home a Veteran?
Your answer
Are there any elders currently living with you? Do they have any special needs? Please state their name and age.
Your answer
If possible, may you please list all of your vendor(s) below? Examples: Allaround Propane, NTUA, Tse Bit'Ai Propane, etc.
Your answer
What kind of assistance are you seeking today? Please check a maximum of 3.
Coal Card
Housing Discretionary
Homesite Lease
Sewage
Food
Electricity
Running Water
Wood (Depends on the season and the availability)
Other:
How would this assistance benefit your family?
Your answer
Does your current living location have a Homesite Lease? Is the Homesite Lease in your name?
Your answer
If you do not have running water or electricity, what can we do to assist you? Do you need water bottles, water jugs, flashlights, solar energy, etc.? Please Explain below,
Your answer
STUDENT/CHILD(REN) INFORMATION
This is for any child living in your home currently.
Click HERE if this bottom portion is not applicable to you.
This portion is not applicable to me.
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How many children are in your home?
Your answer
Are there any infants? If so, how old?
Your answer
How many of them are in school currently?
Your answer
Are they learning remotely or online?
Remotely
Online
Other
Clear selection
Do you utilize the School Bus lunches that the Central Consolidated School District provides?
Yes
No
Sometimes
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Please use the space provided below to State your child(ren)'s name, age and their grade. You may also use their Academic Position as well; College, High School, Middle School, Elem. Pre-k, Etc.
Your answer
What assistances would benefit them, so that they may continue their education? Please check a maximum of 3.
School Supplies
Scholarship
Student-Aide
Other
Please insert your Email Address if you have one.
Your answer
You may use this space for any comments or recommendations. We appreciate your time!
Your answer
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