HIC Afghan Women Project
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First Name *
Family Name *
Date of Birth *
MM
/
DD
/
YYYY
Address (Street) *
Zip *
Telephone Number *
Email *
Primary Language *
Highest Level of Education Completed *
How many school aged children do you have? *
How many of your children are not in school? *
What is the total number of people in your home? *
Please check all that apply. *
Required
Do you have any other issues?
Are you working with an agency/agencies? *
If you are working with an agency/agencies, please provide their name(s).
Do you know how to drive a car? *
Do you own a car? *
Is a family member available to drive you to appointments? *
Which activities do you like to do in your free time? *
Required
When are you available to meet for the program?
Monday
Tuesday
Wednesday
Thursday
Friday
Morning
Afternoon
Evening
Terms & Conditions / Privacy Notice (Click the link to view the terms and conditions) *
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