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Potential Member Interest Form
Interested in joining Just People? We would love to get to know you!
Please fill out this form so our Intake Coordinator, Natalie Christianson, can send you an information packet and contact you for further intake.
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* Indicates required question
Potential Member Name
*
Your answer
Contact Name
*
Your answer
Contact Relationship to Potential Member
*
Your answer
Contact Person Phone
*
Your answer
Contact Person Email
*
Your answer
How did you hear about Just People?
*
Your answer
Program Interest
*
Independent Living Program
Day Program
Both
Location Interest
*
Hall
Fulton
Either
N/A - Day Program Interest Only
How would you like to receive our information packet?
*
Mail
Email
Any other information?
Your answer
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