We Are Better Together Community Day
This event is free and items are while supplies last. All information collected is confidential and used only to understand the population being served and aid in providing services.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
City of Residence
*
East Orange
Irvington
Newark
Other
E-mail
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Will you be accepting groceries?
*
Please Select
Yes
No
Are you a U.S. Military Veteran
*
No
Yes, I'm Active Military
Yes, I'm Retired
Other
How did you hear about this event?
*
Social Media (Facebook, Instagram, LinkedIn etc.)
Word of Mouth
Flyer
UCC's Website
I give United Community Corporation (UCC) permission to use at any time the audio video media, likeness, and written or creative work of, and quotations from my child(ren) family and myself in advertising, publicity of promotional material for the center, both in print and electronic media, without notice or monetary remuneration to myself, my family or my child(ren). There is no expiration date to this permission.
*
Yes
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Household Information
This Information provided through this form is used to assist UCC in expanding the services we provide by identifying the demographics of the clients we serve.
Household Income
*
Please Select
No Income to $12,000
$26,000 to $40,000
Over $40,000
# of Children (Ages 0 - 18)
*
Please Select
None
1
2
3
4
5
6
7
8
9
10
# of Adults (Ages 18 - 62)
*
Please Select
None
1
2
3
4
5
# of Seniors (Over age 62)
*
Please Select
None
1
2
3
4
Race/Ethnicity
*
African American
Hispanic / Latino
Caucasian
Asian
Prefer Not To Say
Other
Gender
*
Male
Female
Other
Signature
*
Submit Form
Submit Form
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