Name:
Date of Birth:
Address:
City: State: AK AL AR AZ CA CO CT DC DE FL GE HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TE TX UT VA VT WA WI WV WY Zip:
Home Phone:
Work Phone:
Cell Phone:
Spouse: Date of Birth:
Dependent: Date of Birth:
How long have you lived in the Dallas/Ft. Worth area?
Are You currently employed?
Yes No
If yes, what is your occupation?
Employer:
How did you hear about CLC Care, Uplift, or Christian Life Center?
Were you refered by someone?
If yes, Who?
Have you or anyone in your household been enrolled in UpLift previously?
If yes, When?
What life skills are you interested in improving? (check all that apply)
Financial Management/ Planning
Family Relationships
Marriage
Parenting
Interpersonal Relationships
Other
Other:
How can CLC Care and UpLift help you? (Example: creating a budget, writing a resume, etc.)
Do you understand the program requirements?
By checking this box, I am providing an electronic signature. I understand that I am applying for the UpLift program, and that application does not guarantee acceptance.
