Nonprofit CRM Template for Newbies
Intake Information
Application Date
-
Month
-
Day
Year
Date
Program Site
Please Select
Site 1
Site 2
Site 3
How did you hear about us
Alumni
Friends or family
Organizational referral
Probation or parole officer
Community event
Court referral
Instagram
Facebook
Website
Other
Have you participated in our programs before?
Yes
No
Participant name
First Name
Last Name
Date of brith
-
Month
-
Day
Year
Date
Are you authorized to work in the US?
Yes
No
Mobile phone number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact (name, phone, address)
Gender
Male
Email
Non-binary
Prefer not to say
Race / ethnicity
Black or African American
Hispanic or Latino
White or Caucasian
Native American, Hawaiian or Pacific Islander
Two or more races/ ethnicity
Prefer not to say
Are you a veteran?
Yes
No
Men only: Are you registered with the Selective Service System?
Yes
No
Unsure
N/A (I am a woman)
Do you have a disability?
Yes
No
Prefer not to say
What is your current housing status?
Rent
Own
Stay with family or friends
Foster care
Shelter
Treatment center
Homeless
Is your housing temporary or permanent
Temporary
Permanent
26. What is the highest level of education you have completed?
None
High school diploma
High school equivalency
Some college
Associate's degree
Bachelor's degree
Master's degree or higher
Are you currently in a school or an education program?
Yes
No
Do you have any vocational training or certifications?
Yes
No
Do you have a valid driver’s license?
Yes
No
Is English your primary language (or preferred language of communication)?
Yes
No
Do you speak any other languages besides English? Select all that apply.
None
Spanish
French
Creole
Mandarin
Russian
Other
Program Start Date
Program start date
-
Month
-
Day
Year
Date
Eligibility documents
Photo ID
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Choose a file
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of
Birth Certificate
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of
Social Security Card
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of
Proof of Address
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of
Proof of Income
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of
Client status
Client Status
Active
Inactive/Disengaged
Case notes
Case Notes
Program attendance
Attendance information
Placement
Placement information
Program completion date
Program completion date
-
Month
-
Day
Year
Date
Submit
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