AmeriCorpsApp_Page4 – Lessie Bates Davis Neighborhood House

Optional Demographic Information

Ethnic Background:

Gender Identity:

Do you have any special needs that require accomodation?

If yes, please specify:

Does your family receive public assistance (e.g. TANF, Food Stamps, Medical Card)?

If yes, please specify:

Annual Household Income:

How many people reside in your household?

Signature:

Date:

If the above information is correct, type your name below and click on the button to the right to proceed to the next step of the application

Please type your full name below before submitting your completed application.

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[field id="ethnicity"]

[field id="gender"]

[field id="accomidations"]

[field id="accomo_exp"]

[field id="public_assist"]

[field id="public_explanation"]

[field id="income"]

[field id="household"]

[field id="sig_date"]