We care about you. Tell us about yourself, and what you need. Sharing your situation gives us some information to understand your situation, and how we might help. Please answer each question accurately and thoughtfully. Be confident your information is confidential; and you will remain anonymous. If you have questions or need assistance completing this form, please contact us at info@wingsforjustice.com.

* 1. Contact Information

* 2. Are you male or female?

* 3. What is your age?

* 4. How many children are you a parent or guardian for and live in your household (aged 17 or younger only)?

* 5. Which of the following best describes your current relationship status?

* 6. Who, if anyone, currently lives with you in your household? Please include permanent residents only. (Please select all that apply.)

* 7. Which areas do you need help with at this time? (Please select all that apply.)

* 8. What is the highest level of school you have completed or the highest degree you have received?

* 9. Which of the following categories best describes your employment status?

* 10. Has anyone in your household ever served in any branch of the United States military, or not?

* 11. How much total combined money did all members of your HOUSEHOLD earn last year?

* 12. Do you currently receive government food assistance, or not?

* 13. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

* 14. Do you identify with any of the following religions? (Please select all that apply.)

* 15. Do you have any other comments, questions, or concerns?

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