CCILC EVENT REGISTRATION FORM 2022

ATTENTION: For consumers only or those willing to become consumers! You must be a person with a disability residing in Camden City. Call our office for more information at 856-966-0800.

Are you a consumer?* This field is required.A consumer is a person with a disability who lives in Camden City, and is already registered with our office for services. If you are not already a consumer, but would like to become one, please contact our office at 856-966-0800.

Yes

Willing to become a consumer

Are you a person with a disability?* This field is required.This can include but is not limited to physical impairment, sensory impairment, cognitive impairment, intellectual impairment, mental illness, and various types of chronic disease.

Yes

Do you live in Camden City, New Jersey* This field is required.

Yes

Full Name* This field is required.

First Name

Last Name

Address* This field is required.If you live in an apartment complex please include the name of the apartment complex as well.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Phone Number* This field is required.

Please enter a valid phone number.

example@example.com

Children's Program* This field is required.

Joys of Toys for Rae's Kids (registration deadline 11/21/2022) Age range 0-9 years old

Pajama and Book Giveaway (ongoing) Up to age 10 years old

Pencil Project (registration deadline 8/5/2022) Up to age 14 years old

Spring and Summer Bag (Ongoing) Age Range 0-10 years old

Scientists at Home Program (Ongoing) Up to age 10 (July Event)

None

Young Adult ProgramsAge Range (16 to 17 years old)

Money Management Program

Drivers Education Program (Written Test)

Summer Internship

Workplace Readiness

Mock Interview Practice

Job Search Strategies

Job Skills Training

Resume Writing

Young Adult Social

None

Holiday EventsSpace is limited to the first 25 registrants

Turkey Palooza (Deadline to Register October 29th 2022 by 12pm)

None

Covid-19 Programs and Events* This field is required.Free

Face Mask (ongoing)

Covid-19 Testing Kit (ongoing)

None

Life Skills* This field is required.Age Range (18+)

Zoom Training

Drivers Education

Money Management

Emergency Preparedness: Go Bag Program

Housing Assistance Workshops (ongoing)

None

How many people live in your household?This includes yourself and anyone you have custody of. Please do not list people for whom you are not responsible such as roommates or other families sharing your living space.

How many people live in your household?* This field is required.This includes yourself and anyone you have custody of. Please do not list people for whom you are not responsible such as roommates or other families sharing your living space.

HOUSEHOLD INFO: This section is used for children's programs and COVID-19 services, skip if it is not applicable.

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Boy or Girl

Age

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Boy or Girl

Age

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Boy or Girl

Age

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Boy or Girl

Age

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Boy or Girl

Age

Child's Name

Date of Birth

School Name

Grade

Clothes Size

Boy or Girl

Age

Do you have custody of the child(ren) listed above?

Yes

Due to the pandemic many of our services are virtual or drive-thru events. If the event you are interested in participating is a drive-thru event, will you have access to a ride or transportation?* This field is required.

Person completing the application* This field is required.Please type your full name

Date* This field is required.

Date

I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me from services or cause a delay in assistance. * This field is required.

Full Name

CCILC EVENT REGISTRATION FORM 2022